The Upper Endoscopy (EGD) 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, endoscopy, egd, upper gi, 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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# Upper Endoscopy (EGD) 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:** ___________ --- ## 1. Description of the Procedure Esophagogastroduodenoscopy (EGD), commonly called upper endoscopy, is a direct visual examination of the esophagus, stomach, and duodenum (the first portion of the small intestine) using a thin, flexible, lighted instrument called an endoscope. The endoscope is passed through the mouth, down the throat, and into the upper digestive tract. During the examination, the physician can inspect mucosal surfaces, obtain tissue samples (biopsies), remove polyps, dilate narrowed areas (strictures), inject or apply hemostatic agents to control bleeding, place clips or bands, remove foreign bodies, place feeding tubes, or perform other therapeutic maneuvers. The procedure is performed with topical throat anesthesia and/or intravenous sedation. **Indication(s) for this procedure:** ___________ --- ## 2. Expected Benefits Upper endoscopy provides direct visualization and tissue sampling capabilities superior to imaging studies for upper GI pathology. Potential benefits include: - Accurate diagnosis of esophageal, gastric, and duodenal conditions including ulcers, gastritis, Barrett's esophagus, celiac disease, and malignancies - Detection and treatment of upper GI bleeding sources (esophageal varices, ulcers, Mallory-Weiss tears, angiodysplasia) - Dilation of esophageal strictures to relieve swallowing difficulty - Removal of polyps or early superficial cancers (endoscopic mucosal resection or submucosal dissection) - Eradication of Barrett's epithelium (radiofrequency ablation, cryotherapy) - Evaluation and treatment of GERD complications