digestive disease center of ct

Joel J. Garsten, M.D., F.A.C.P., F.A.C.G., A.G.A.F. Albert R. Maraano, M.D., F.A.C.P., F.A.C.G., A.G.A.F. Your doctor has requested that you receive a special examination. This instruction sheet is designed to tell you about this procedure and how you will be prepared for it. Please ask your nurse or doctor if you have any questions not covered here. WHAT IS THIS TEST?
A proctosigmoidoscopy (flexible sigmoidoscopy) is recommended when a change in bowel habit,
diarrhea, pain, or bleeding from the rectum occurs. The examination is performed with a flexible fiberoptic
sigmoidoscope. The doctor will be able to visualize the lining of the rectum and most of the left colon
(called the sigmoid and descending colon).
Special medications will be given to ease any discomfort. All regular medications should be taken on the day of the procedure (after you arrive home) except as directed by the doctor. DO NOT EAT OR DRINK AFTER MIDNIGHT THE NIGHT BEFORE THE PROCEDURE
You must have someone drive you home after this procedure. PLEASE CHECK WITH YOUR
DOCTOR IF YOU ARE TAKING ASPIRIN PRODUCTS OR BLOOD THINNERS TO
DETERMINE IF HE WANTS THEM STOPPED BEFORE THE PROCEDURE.
IT IS IMPORTANT TO LET THE DOCTOR KNOW IF YOU HAVE ANY ALLERGIES.
DAY OF THE PROCEDURE:
Use two Fleet enemas 1 to 1½hrs. before you are due to be at the hospital. Insert the first one, retain it
for approximately 15 minutes, evacuate it, and then repeat the procedure with the second one.
YOUR PROCEDURE IS SCHEDULED FOR: __________________________________________ AT:________________________HOSPITAL, BY DR:___________________________________ _____Hospital Of Central Ct. (Bradley Memorial Campus): 55 Meriden Ave. Southington, CT 06489. One half hour early, go to the Special Procedures Dept. Procedure will be performed there. _____Waterbury Hospital 64 Robbins St. Waterbury, CT 06721, One hour early, go directly to the GASTROENTEROLOGY DEPT. on the First Floor. (Exception: If you are scheduled for 7:30 a.m. please arrive at the Gastroenterology Dept. at 6:45 a.m.) Valet service is available from 6:30 a.m. to park your car. 60 Westwood Ave., Waterbury, CT 06708 (203) 574-3007 55 Meriden Ave., Southington, CT 06489 (860) 276-9334 The following is a list of products containing aspirin, aspirin-like compounds, Ibuprofen, and Naproxen sodium. PLEASE DO NOT TAKE THESE PRODUCTS FOR ONE WEEK PRIOR TO YOUR PROCEDURE. Prescription products containing aspirin or aspirin-like compounds: Prescription Products Containing Ibuprofen: Motrin Tablets Children's Advil Suspension Children" s Motrin Suspension Prescription Products Containing Naproxen/Naproxen Sodium: Nonprescription Products Containing Ibuprofen: Advil Caplets/Tablets Advil Cold, Sinus Caplets Bayer Select Ibuprofen Pain Relief Formula Caplets Dristan Sinus Caplets Ibuprofen Caplets/Tablets Midol IB Tablets Motrin IB Caplets/Tablets Nuprin Ibuprofen Caplets/Tablets Sine-Aid IB Non-Prescription Products Containing Aspirin and/or Aspirin-like Compounds: Non-Prescription Products Containing Naproxen Sodium:
FOR PATIENT’S GOING TO THE HOSPITAL OF CENTRAL CT (BMH):
THE FOLLOWING MEDICATIONS ARE NOT TO BE TAKEN THE MORNING OF YOUR PROCEDURE.
BRAND NAME
GENERIC
Joel J. Garsten, M.D.,F.A.C.P,., F.A.C.G., A.G.A.F. Albert R Marano, M,D.,F.A.C.P., F.A.C.G., A.G.A.F. This is an explanation of the procedure you are going to have. After you have read it, you will be asked to sign it; giving the doctor permission to perform the test. A proctosigmoidoscopy (flexible sigmoidoscopy) is recommended when a change in bowel habit, diarrhea, pain, or bleeding from the rectum occurs. The examination is performed with a flexible fiber optic sigmoidoscope. This test can usually be performed in the office without medication. The doctor will be able to visualize the lining of the rectum and most of the left colon (called the sigmoid and descending colon). You will be asked to lie on your left side. The instrument will be inserted into the rectum. The doctor will put air through the instrument to open the pathway through the colon. This may cause some abdominal discomfort. Biopsies (small tissue samples) of suspicious areas can be taken and sent to the laboratory. As with any test, there may be complications. We want you to be aware of these possibilities. If bleeding from the site of biopsy is more than usual, cautery may be needed. Rarely, severe uncontrolled bleeding may require blood transfusions or even surgery. Perforation or a tear in the lining of the bowel may occur. This complication may require surgery. You may feel bloated or gassy for several hours after the test because of air introduced during the test. Any other symptoms should be reported to the doctor immediately. I UNDERSTAND THE BENEFITS AND POSSIBLE RISKS ASSOCIATED WITH THIS PROCEDURE AND GIVE PERMISSION TO DR_________________________________ TO OUR MEDICARE PATIENTS: Medicare deems this procedure "routine" and, therefore, will only provide reimbursement if performed for one of the following diagnoses: COLITIS, COLONIC POLYP, DIVERTICULITIS, HEMATOCHEZA, CROHN'S DISEASE, RECTAL BLEEDING. Your signature indicates that you understand and accept this principle and are responsible for payment. Print Name:_________________________________________________________________ PATIENT SIGNATURE:_________________________________ Date:_________________ WITNESS:__________________________________________________________________ Digestive Disease Center of CT
60 Westwood Ave.
Waterbury, CT 06708
203-574-3007
SUMMARY OF NOTICE OF PRIVACY PRACTICES
By Law, we are required to provide you with our Notice of Privacy Practices. This Notice describes how
your medical information may be used and disclosed by us. It also tells you how you can obtain access to
this information.
As a patient, you have the following rights:
1. The right to inspect and copy your information. 2. The right to request corrections to your information. 3. The right to request that your information be restricted. 4. The right to request confidential communications. 5. The right to a report of disclosures of your information. 6. The right to a paper copy of this notice. Please be advised that we may:
1. Call your name when the doctor is ready to see you. 2. Leave test results or messages on your answering machine. 3. Take your charts out of the office for dictation, review, or to see you in our satellite office. 4. Call your place of employment and ask to speak with you. We want to assure you that your medical/protected health information is secure with us. This Notice contains information about how we will insure that your information remains private. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
The undersigned Patient or legally authorized representative (“Agent”) of the Patient acknowledges that he or
she personally received a copy of the DIGESTIVE DISEASE CENTER OF CT’S Notice of Privacy Policies
on the date below.
Signature:________________________________________ Date:__________________________
Patient (print)_________________________________________________________________________
Information about Agent (attach appropriate documentation):
Agent:_______________________________________________________________________________
Title:________________________________________________________________________________
I grant permission to DIGESTIVE DISEASE CENTER OF CT to share my Protected Health
Information with the following individuals:
Name:___________________________Phone#________________Relationship to Patient____________
Name:___________________________Phone#________________Relationship to Patient____________
Name:___________________________Phone#________________Relationship to Patient____________
Signature of Patient:____________________________________ Date:_______________________

Source: http://ddcct.com/flex_1_.pdf