Medsil Endoscopic Intragastric Balloon Information and Consent Form
6 Months-Saline Filled-Balloon

On the date of , the patient had a Medsil endoscopic 6-month saline-filled intragastric balloon with methylene blue dye, which is required to be removed by endoscopy within the next 6 months as a maximum period of time. The removal date was calculated for the patient as the end of , not later than this time. It was clearly explained to the patient about the importance of the removal time, including its risks and complications, and the removal procedure itself in detail.

The patient was also informed to check her urine during each urination and to go to the closest emergency department immediately if she notices any color change in the urine, such 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 agree that healthcare provider(s) involved in my care at this facility will access my health information through the Health Information Exchange System (NABIDH) in accordance with the Laws of the United Arab Emirates, Emirate of Dubai Legislation, and Dubai Health Authority Policies."

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 full responsibility for my decision in this consent.