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1. Come with nothing to eat or drink for a minimum of 12 hrs. If you have been instructed to take your medications, take it with just a sip of water. DO NOT TAKE ANY PILLS THAT ARE RED. 2. You will wear a belt for 7-8 hrs. and return to the office to have the belt removed. 3. Do not have a MRI during the capsule procedure. 4. Do not take iron products for one week prior to exam. 5. Inform us of any abdominal x-rays taken within the last year. DAY BEFORE TEST:
Drink lots of water 2 days before test. Light lunch day before and NO dinner. Eat light lunch at noontime, i.e., sandwich After lunch follow clear liquid diet until 12 hours prior to appointment. You may have water, ginger ale, white Italian ice. No solid food No coffee or tea No iron tablets for 7 days before your test. No antacids or Sucralfate (Carafate) for 24 hrs. before your test. No smoking for 24 hours before you test No drinking for 12 hours before your test, unless you need to take medications with a sip of water. You may take your medications up to 2 hours prior to the test with a sip of water, or as advised by the doctor. If you take medications that delay gastric emptying, such as calcium channel blocker (Cardizem, Norvasc, Procardia, Verapamil, etc.) please follow the instructions given to you by the doctor. Patients with diabetes may be asked to adjust their Insulin dose. You may take Coumadin or Aspirin Male Patients: please shave the areas indicated in the enclosed diagram for PATIENT’S NAME____________________________________DATE___________________ TIME THE CAPSULE WAS SWALLOWED________________________________________ RETURN FOR EQUIPTMENT REMOVAL_________________________________________ You have just undergone a capsule endoscopy. This sheet contains information about what to expect while wearing the equipment. Please call our office 203-574-3007 (option #2) if you have: Severe or persistent abdominal or chest pain Fever Difficulty swallowing Nausea/Vomiting Any questions 1. Two hours after you swallow the capsule: You may drink clear liquids such as: water,
apple or other white juices, ginger ale, 7-up, white Italian ice, weak coffee or tea. Four hours after you swallow the capsule: You may take you medications.
You may eat a light meal such as a sandwich, salad, etc. – NOTHING RED, i.e. TOMATOS. 2. DO NOT exercise, and avoid heavy lifting. You may walk, sit, lie down, and drive a car.
You may return to work, if work allows avoiding unsuitable environments and/or physical 3. Avoid gong near MRI machines, X-ray and radio transmitters until the capsule passes through your GI tract. You may use a computer, radio, cell phone, and stereo, and other 4. DO NOT stand directly next to another person undergoing a capsule endoscopy.
5. Try not to touch the recorder or the sensor leads. DO NOT remove the leads or recorder.
6. The data recorder is an expensive computer; please avoid getting the recorder or leads wet. 7. You may loosen the belt to allow yourself to use the bathroom, but DO NOT take the belt off
8. Observe the Blue LED light on the data recorder at least every 15 – 30 minutes. If the light stops blinking, document the time and call our office right away. PLEASE BRING THIS CONSENT FORM WITH YOU THE DAY OF THE PROCEDURE. Patient name: __________________________________Date of exam:_______________________
I consent to having a capsule endoscopy, which is a non-invasive and ambulatory procedure that
permits visualization of the patient’s GI tract, especially the small intestine. It does not replace an
upper endoscopy or colonoscopy. I understand that there are risks associated with any endoscopic
exam, such as bowel obstruction. I would contact my doctor immediately at 203-574-3007 if I were
to suffer from any abdominal pain, nausea or vomiting. An obstruction may require immediate
surgery. If the capsule gets stuck when swallowing, I may need to have it endoscopically inserted.
I am aware that I should avoid MRI machine, x-rays and radio transmitters during the procedure and
until the passage of my capsule.
I do understand and have complied with all of the pre-procedure instructions.
I understand that I will not disconnect the equipment or remove the belt during that time period,
since the data recorder is actually a small computer and should be treated very carefully. I will avoid
sudden movements and will not bang the data recorder.
I understand images and data from the endoscopy may be used under complete confidentiality for
educational purposes and future medical studies.
I understand the possibility of surgery may be needed if the capsule is not naturally excreted.
Dr._____________________, or his trained office representative, has explained the procedure and
its risks, as well as the alternatives of diagnosis and treatment, and I have been allowed to ask
questions concerning the planned examination.
I authorize Dr.__________________ and his staff to prepare, instruct and guide me in the ingestion
of the capsule. I understand that Dr.____________________ will be performing the reading of the
data to interpret the capsule endoscopy.
Print Patient Name:_____________________________________ Date:____________________
Patient Signiture:_______________________________________

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