Informed consent for flexible sigmoidoscopy examining the rectum and left colon, including preparation, risks, benefits, alternatives, and patient acknowledgment.
The Flexible Sigmoidoscopy 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, sigmoidoscopy, endoscopy, colorectal, 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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# Flexible Sigmoidoscopy 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 Flexible sigmoidoscopy is a visual examination of the rectum and sigmoid colon (lower portion of the large intestine, typically the distal 40–60 cm from the anus) using a thin, flexible, lighted instrument called a sigmoidoscope. Unlike colonoscopy, the examination does not extend to the full colon. The procedure is performed with a limited bowel preparation (one or two enemas) and usually does not require intravenous sedation, though sedation may be offered at some institutions. The physician can visualize the mucosal lining, obtain biopsies, remove small polyps, and assess for sources of bleeding or inflammation in the examined segment. **Indication(s) for this procedure:** ___________ --- ## 2. Expected Benefits - Detection of polyps, cancer, inflammation, or bleeding sources in the rectum and sigmoid colon - Colorectal cancer screening (in combination with fecal testing, or as a standalone screening modality) - Evaluation of rectal bleeding, change in bowel habits, or anorectal symptoms - Assessment of known or suspected inflammatory bowel disease affecting the distal colon - Follow-up evaluation after surgery or prior endoscopic treatment in the distal colon - Avoidance of full bowel preparation and sedation in appropriate patients --- ## 3. Procedure-Specific Material Risks