Informed consent for wireless capsule endoscopy of the small bowel (and optionally colon or esophagus), including risks of capsule retention, preparation requirements, and patient acknowledgment.
The Capsule Endoscopy Informed Consent is a ready-to-use healthcare & wellness template you can send for signature in minutes. It is written for 1 signer (patient) and, by default, expires 30 days after it is sent if left unsigned. It covers consent, gastroenterology, capsule endoscopy, small bowel, imaging, healthcare. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Capsule Endoscopy Informed Consent > **Important — not medical advice.** For use by a licensed provider; tailor risks/benefits/alternatives to the patient and your institution's protocols and state law. **Patient Name:** ___________ **Date of Birth:** ___________ **Medical Record Number:** ___________ **Ordering Physician:** ___________ **Scheduled Procedure Date:** ___________ **Capsule System (e.g., PillCam SB, OMOM, EndoCapsule):** ___________ --- ## 1. Description of the Procedure Capsule endoscopy is a non-invasive, wireless imaging study in which you swallow a small pill-sized camera (the capsule). As the capsule travels through your digestive tract propelled by natural gut motility, it captures thousands of photographs per second and transmits them via radiofrequency to a data recorder worn on a belt or vest around your waist. The capsule is disposable and passes naturally through the digestive tract. The images are downloaded from the recorder and reviewed by your physician to identify abnormalities along the mucosal surface of the small intestine (and, with specialized capsule systems, the esophagus or colon). **Primary segment being evaluated:** ___________ **Indication(s) for this procedure:** ___________ --- ## 2. Expected Benefits Capsule endoscopy provides visualization of the small intestine — a segment that is poorly accessible by conventional upper endoscopy or colonoscopy. Benefits include: - Evaluation of obscure gastrointestinal bleeding (bleeding that has not been identified by EGD or colonoscopy) - Detection of small bowel tumors, polyps, arteriovenous malformations (AVMs), or angioectasias