I consent to have the following diagnostic examination performed by Dr. Goldstein, Dr. Prosky, or Dr. Vemana.
Please read the following statements:
I understand that there may be risks associated with any endoscopic examination. Potential complications may include risk of drug reaction, localized swelling of the arm following intravenous medication, or bleeding. Serious complications such as bleeding or perforation of the intestinal wall can occur but are usually associated with polypectomy or dilation. Excessive bleeding may require blood transfusions and perforation may require surgical intervention.
Procedure Cancellation/Rescheduling Policy: (Please initial to acknowledge the statements below.)
Transportation Policy: (Please initial to acknowledge the statements below.)
**PLEASE NOTIFY OUR OFFICE IF YOUR INSURANCE PLAN CHANGES BEFORE THE DATE OF YOUR PROCEDURE**
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