Spatz 3 Endoscopic Intragastric Balloon (12 Months-saline filled balloon) Information and Consent Form

Patient’s Name:
File No.:
DOB:
Mobile Number:
Visit Date:
Registration Time:
Doctor Name:

Procedure: Spartz 3 Endoscopic Intragastric Balloon (12 months-salinefilled-balloon)
Facility:

On the date of the patient has Spatz 3 endoscopic 12 months saline filled intragastric balloon with methylene blue dye, which is required to be removed by endoscopy within the next 12 months as a maximum period of time. And the removal date was calculated for her as at the end of not after of this time. It was clearly explained to the patient about the importance of the removal time with its risks and complications and the removal procedure itself in details.

The patient was also informed to check her urine in each urination and to go to the closest emergency department immediately if she realized any color change in the urine. As bluish or greenish.

This report was prepared to inform the patient and the medical team who will remove the balloon.

I understand and agree that I am financially responsible for the payment I made for that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months period. I agree that my payment made is non-refundable or non-transferable post this period.

I declare that I have read and fully understood all points in this consent and that all of my questions were answered to my satisfaction and I take the full responsibility of my decision in this consent.

 

Patient Name & Signature :   

Doctor/Therapist Name & Signature :   

Witness Name & Signature :     

Parent or Gaurdian Name (if patient is minor) :

Date :