CONSENT FOR UPPER ENDOSCOPY - virginia 2025

1. Click ‘Get Form’ to open the CONSENT FOR UPPER ENDOSCOPY document in the editor.
2. Begin by filling in your personal information at the top of the form, including your name and medical record number if a label is not available.
3. In Section A, authorize the physician(s) by writing their names as listed. Ensure you understand the procedures being consented to, including any potential biopsies or additional interventions.
4. Provide your diagnosis or condition in the designated field, ensuring clarity for accurate documentation.
5. Review and acknowledge your understanding of the risks and benefits associated with the procedure. This section is crucial for informed consent.
6. In Section B, consent to anesthesia or sedation by checking appropriate boxes and acknowledging understanding of associated risks.
7. Sign and date at the bottom of Section C, confirming that you are either 18 years or older or authorized to consent on behalf of a minor.

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