M. Asif Mohiuddin, M.D.
Orlando • 2880 S. Osceola Avenue • Orlando, FL 32806
Kissimmee • 901-CE. Oak Street • Kissimmee, FL 34744
St. Cloud • 3114 17th Street • St. Cloud, FL 34769
407-843-0443 • Fax: 407-847-0775
Dr. M. Asif Mohiuddin is going to examine your esophagus, stomach and duodenum with a long flexible tube (endoscope) to determine if any disease processes are present. This will help him to understand and treat your symptoms. Often a problem or disease will not be seen on X-ray. Proper preparation is very important for this examination and requires that you have an empty stomach; therefore, please do not eat or drink after midnight the night before this examination unless otherwise instructed. When you arrive at the Endoscopy Room, your throat may be sprayed with a medicine to numb it. This is Novocaine or Xylocaine. You may be given sedatives intravenously (IV) just prior to the examination to cause relaxation. If you have had an unfavorable or allergic reaction to any drugs, please notify the physician or nurse before the medication is given. The drugs cause sedation and drowsiness and in fact, some people do not remember having the test done.
The examination is carried out with you lying on your left side on the examining table/stretcher in a partially darkened room. A nurse is present to help the physician and check on you frequently. A long flexible tube (endoscope) is placed in the mouth and as you swallow, the physician advances the tube into the esophagus. A mouth guard is usually present to rest the teeth on and to protect the instrument. As the examination is conducted, the physician instills a small amount of air into the esophagus and stomach and he may remove secretions by suction. You may feel some fullness and distention from the air. As the instrument is passed beyond the stomach into the duodenum, or small intestine, there is usually a tugging sensation. This is not a painful examination, although there may be gagging sensation initially, which tends to resolve as the procedure continues. You may have a slight sore throat after the procedure for a day or so. If biopsy is necessary, tiny bits of tissue can be removed with this instrument so that a pathologist can examine them. This does not cause pain and there is no feeling associated with taking biopsies.
Alternative procedures are barium meal.
1. I hereby authorize Dr. M. Asif Mohiuddin to perform an Esophagogastroduodenoscopy (EGD). I understand and agree that this procedure involves: Passing a tube into the mouth for the purpose of visualizing a portion of the esophagus, stomach, first portion of the small intestine, with possible biopsy, removal of polyps, possible brushing (obtaining a specimen for study), dilation, (stretching of a portion of the esophagus), possible coagulation (stopping bleeding), possible decompression (removal of pressure) and or photography/video.
2. I understand during the course of this procedure (s) or sedation, unforeseen conditions may become apparent which require an extension of the original procedure(s) or additional treatment(s) from that described above. I therefore, authorize Dr. M. Asif Mohiuddin to perform such procedure(s) or additional treatments) as they, in the exercise of his professional judgment, deem necessary.
3. I understand and agree that there are risks involved in this procedure: a. That may include, but are not limited to: Hemorrhage (bleeding), perforation (poking a hole in the intestine), that may require surgery, distention (bloating), explosion of intestinal gases, cardiac/respiratory complications, allergic drug reaction, and/or hypotension (lowered blood pressure). In rare cases, may lead to death or permanent or partial disability.
b. I understand that Dr. M. Asif Mohiuddin will do everything possible to prevent these complications but that he cannot guarantee that they will not c. I acknowledge that no guarantee has been made to me as to result or cure, I understand the benefits, risks and complications of this specific procedure.
4. I also acknowledge that reasonable acceptable alternate courses of therapy are barium x-ray studies and the benefit, risks and complications of those 5. I understand that the small lesions can be missed by gastroscopy Rarely early gastric cancer can also be missed during this procedure.
6. I understand my right to refuse the recommended procedure(s), the options available to me should I refuse to consent, and the expected consequences of 7. I have had sufficient opportunity to know about my condition and the planned procedure(s) and all of my questions have been answered to my satisfaction. I understand my condition and planned procedure(s) and I have adequate knowledge upon which to base an informed consent.
8. I consent the administration of sedation by Dr. M. Asif Mohiuddin or other qualified party under the direction of a physician as may be deemed necessary. I understand that all sedation involves risks of complications and possible damage to vital organs.
Signed: _________________________________________________________________ Date: _____________________ Patient/Legal Representative’s Signature

Source: http://tummydoctor.org/EGDConsentForm.pdf


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