Step 1. Print Referral Form & take it to your Doctor
Step 2. Call us on 9781 5959 to make an appointment or Book Online
Step 3. Click here to Read the Appointments Page
 
  • Step
  • Step
  • Step
  • Step
  • Step
  • Step
  • Step
  • Step

General Information

Questions marked * are mandatory
OFFICE USE
ANAESTHETIST NAME:
SIGNATURE:
DATE:
PATIENT APPROVED FOR PROCEDURE:
YES      NO
BMI:
VARIANCE IN ADMISSION (EG PAC Required, change of Medications etc):
Bowel Prep Suggested:
3 Picosalax   4 Picosalax
Alternate Bowel Prep Solution:
Referral for review by a Gastroenterologist
 

BOWEL PREPARATION

Questions marked * are mandatory

MEDICATIONS AND ALLERGIES

Questions marked * are mandatory

ANAESTHETIC HISTORY & ASSESSMENT

Questions marked * are mandatory

MEDICAL HISTORY AND ASSESSMENT

Questions marked * are mandatory

DIABETES

Questions marked * are mandatory

INFECTION & INFECTION RISK

Questions marked * are mandatory

PLEASE READ THE FOLLOWING AND DISCUSS ANY QUESTIONS OR CONCERNS WITH OUR STAFF

Anaesthesia Consent

Anaesthetic complications during endoscopy procedures are rare. These range from minor reactions to anaesthetic drugs, prolonged sleepiness and nausea. Severe or life-threatening events such as aspiration or laryngospasm are extremely rare. During endoscopy all attempts are made to protect teeth, however, it is possible for teeth or crowns to be damaged during the procedures.

Anaesthesia related risks & complications have been explained to me and I have been given the opportunity have questions answered.

Procedure Consent

Gastroscopy is a test to examine the inside of your oesophagus, stomach and duodenum. A flexible tube with a camera will be passed through your mouth into the stomach.
Colonoscopy is a test to examine the inside of your large bowel. A flexible tube with a camera will be used through the back passage along the large bowel. Through this tube, the lining of the bowel can be examined and polyps removed.

You will be given an intravenous injection, which will induce a light sleep (sedation). Your anaesthetist will discuss this with you.

Safety and risks

Complications of gastroscopy are very rare and may include bleeding or perforation. For inspection of the bowel alone, complications of colonoscopy are uncommon. Most surveys report complications in 1 in 1000 examinations or less. Complications, which can occur, include an intolerance of the bowel preparation solution and scope disinfection solution used. Perforation (making a hole in the bowel), splenic rupture or major bleeding from the bowel is extremely rare but if occurs, may require surgery. When operations such as removal of polyps are carried out there is a slightly higher risk of perforation and bleeding.

Before you have a colonoscopy, you need to make sure your bowel is as clear as possible. If your bowel is not clear, polyps or even cancers may be missed, or you may need to have the colonoscopy again. This means it is important for you to follow the instructions carefully and ask questions if you do not understand what to do.  To get your bowel ready for the colonoscopy, you will be told what (and what not) to eat and drink, including when to drink extra fluids to stop you from getting dehydrated. You will be given, or asked to buy, medicine to clear out your bowel by causing diarrhoea. Make sure you understand when to take the medicines, usually starting the day before the colonoscopy. Your doctor or nurse will explain how these medicines may affect you. You should tell them about any previous experience you have had with bowel preparation.

Preparation for colonoscopy can also affect your other health conditions or medicines, such as medicines for diabetes or medicines to prevent blood clots. You may need to change the way you take your other medicines or follow special instructions in the days before your colonoscopy. Your Clinician will discuss with you any changes you may need to make. Some people may need extra personal or health support during bowel preparation and a few may need an overnight stay in hospital.

If at any time during the bowel preparation you are unsure what to do, ring our centre on 9781 5959 to check.

I understand the reason for the colonoscopy, its benefits and potential adverse events including those related to the bowel preparation or sedation, perforation, bleeding (immediate and delayed) and potentially missed pathology. Please call us on 9781 5959 one week prior to your procedure to confirm your informed consent and discuss your preparation.

 
Social media & sharing icons powered by UltimatelySocial