I understand and acknowledge that during the course of my treatment today, the following procedure may be required:

ANOSCOPY, RUBBER BAND LIGATION OF HEMORRHOID

I acknowledge and understand that prior to any procedure being performed, the physician will give me more specific instructions on my diagnosis and procedure process. I acknowledge at this time I will have the opportunity to ask any and all questions I may have. The physician will then proceed only when I have given a verbal informed consent and signed this written informed consent.

Like any procedure there are risks involved, please read carefully:

• I understand that the practice of medicine is not an exact science and acknowledge that I have not received any guarantees, assurances, or promises concerning the results of the procedure. I understand that as a result of the performance of the procedure, there is a minor risk that I may suffer pain, urinary symptoms, loss of blood, infection, or allergic reaction, along with recurrent hemorrhoid symptoms.

 

• The potential benefits and likelihood of success with treatment are very good. I understand and acknowledge that there are alternatives to treatments such as (but not limited to) invasive surgery, infrared coagulation, over the counter (OTC) medications, and not seeking treatment (i.e. living with the condition) If the procedure is rejected the future prognosis is unknown at this time.

 

• I acknowledge and understand that during the course of the procedure, conditions may develop that may reasonably necessitate an extension of the original procedure or the performance of procedures that are unforeseeable or not known to be needed at the time this consent is obtained. In the event of such circumstances, I consent to my treating physician providing treatment to me that he or she deems necessary.

 

• I acknowledge and understand that this request for and consent to procedures shall be valid for the responsible physician, all medical personnel under the direct supervision and control of the physician, and for all other medical personnel otherwise involved in this course of treatment.

By signing below, I acknowledge that I have read this form and had this form read/and or explained to me and that I fully understand this form. I acknowledge that I have been given ample opportunity to ask questions and any questions I have asked have been answered or explained in a satisfactory manner. In signing I understand the relative risks, potential benefits and alternatives for hemorrhoid therapy.