Healthcare Digestive Document

HEALTHCARE DIGESTIVE DOCUMENT

Patient Identification

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical & Digestive History

Please provide current and relevant digestive health information. Accurate disclosure is necessary for safe care.

Digestive Symptoms (check all that apply)

Abdominal pain or cramping
Rectal bleeding or bloody stool
Constipation
Diarrhea
Unintentional weight loss
Heartburn / reflux
Nausea or vomiting
Iron deficiency / anemia
Change in bowel habits
Other:

Medication and Peri‑Procedural Considerations

Are you taking anticoagulant or antiplatelet medication (for example warfarin, DOACs, clopidogrel, aspirin)?
Yes    No

Are you pregnant, trying to become pregnant, or breastfeeding?
Yes    No    Unknown

Procedure Consent

Procedure to be performed:

I authorize the physician and clinical staff to perform the procedure set forth above, including such diagnostic and therapeutic maneuvers as deemed appropriate. I understand the nature and purpose of the procedure, the expected benefits, and that no guarantee has been made as to results.

Risks and possible complications include, but are not limited to: bleeding, perforation of the gastrointestinal tract, infection, adverse reaction to sedatives or anesthesia, cardiopulmonary compromise, need for transfusion, need for additional procedures or hospitalization, and, rarely, death. The probability of specific complications varies with the procedure and patient condition.

Alternatives to the proposed procedure, including non‑operative management and alternative diagnostic tests, have been explained. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction. I understand I may withdraw consent at any time prior to the procedure.

HIPAA & Release Authorization

I acknowledge receipt of the practice's Notice of Privacy Practices. I authorize the release of my protected health information as necessary for treatment, payment, or healthcare operations and for the purpose of coordinating care related to the digestive condition described herein.

I authorize the release of my records to the following persons or entities for the purpose of care coordination:

May we leave appointment reminders or test results by telephone or voicemail at the numbers provided? Yes No

Patient Certification

By signing below, I certify that the information provided on this form is true and complete to the best of my knowledge. I consent to the treatment and procedures described above and authorize hospital and clinical personnel to perform those procedures. I acknowledge that I have been informed of the risks, benefits, and alternatives, and have had my questions explained.

If signed by someone other than the patient, state relationship and legal authority:

Sign Now