Informed Consent for Flexible Sigmoidoscopy

Procedure Name

Form Sections

Section 1info grid

Facility / Clinic Name

Performing Physician

Patient Full Legal Name

Date of Birth

Medical Record Number (MRN)

Date of Procedure

Sedation Planned

Prep Status (Enema completed)

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Section 13signature block

Patient / LAR Signature

Physician Signature

Witness Signature

Date and Time of Consent

Informed Consent for Flexible Sigmoidoscopy

Patient and Procedure Information

Facility / Clinic Name

Performing Physician

Patient Full Legal Name

Date of Birth

Medical Record Number (MRN)

Date of Procedure

Sedation Planned

Prep Status (Enema completed)

Nature and Purpose of the Procedure

A flexible sigmoidoscopy is a diagnostic procedure to examine the lining of your rectum and the lower third of your colon (the sigmoid colon). Under local or mild sedation (though often performed unsedated), a thin, flexible endoscope is inserted through the anus and advanced into the lower bowel. The physician uses the scope's camera to look for signs of inflammation, ulcers, polyps, bleeding, or cancer. Biopsies may be taken or small polyps removed during the procedure. The exam takes 10 to 15 minutes. It is a more limited examination than a full colonoscopy, which checks the entire large intestine.

Pre-Procedure Preparation

To ensure a clear view, you must empty the lower bowel before the procedure. This is usually done by using one or two tap water or saline enemas (such as Fleet enemas) at home 2 hours before the procedure, as instructed by your clinic. Eating a light diet the day before is recommended. You do not need to drink the large volume of bowel cleansing liquid required for a colonoscopy.

Biopsy and Polyp Removal Authorization

I authorize the physician to take tissue samples (biopsies) from the lining of the rectum or sigmoid colon as needed.

I authorize the removal of small polyps if discovered in the lower bowel.

I authorize the submission of all specimens to a pathology lab for evaluation.

Material Risks and Potential Complications

Bleeding: minor bleeding can occur at biopsy or polyp removal sites. It is usually minimal and stops on its own.

Perforation: a very rare tear or hole in the wall of the rectum or colon. The risk is less than 1 in 10,000 procedures. A perforation requires hospitalization and may require emergency surgery to repair.

Abdominal discomfort: mild cramping, gas, or bloating during and immediately after the procedure is common as air is pumped into the bowel to inflate it.

Sedation risks (if sedation is used): breathing slowing, drop in blood pressure, or localized IV site reaction.

Alternatives to Flexible Sigmoidoscopy

Colonoscopy: a full exam of the entire large intestine, which requires a complete bowel cleanout and sedation but provides a more thorough screen.

Stool tests: tests such as Cologuard or FIT can check for blood or DNA changes but cannot diagnose issues directly or take biopsies.

No exam: monitoring symptoms and checking blood counts without direct bowel screening.

Warning Signs and Post-Procedure Care

Seek immediate medical care if you experience: (1) Severe abdominal pain or swelling, (2) Fever or chills, (3) Rectal bleeding that is continuous or exceeds half a cup, (4) Dizziness or weakness.

Right to Refuse

You have the right to refuse this procedure. The physician will discuss the consequences of not performing the exam, such as leaving rectal bleeding or lower bowel symptoms undiagnosed.

Patient Understanding and Questions

I confirm that I have read this document and understand the flexible sigmoidoscopy procedure, its risks, and its prep requirements. All my questions have been answered.

Language Access

If English is not your primary language, a qualified interpreter is available at no cost. Please inform staff before signing.

Copy of Consent Acknowledgment

I acknowledge that I have been offered a copy of this signed consent form.

Patient Authorization

I voluntarily consent to undergo a flexible sigmoidoscopy with associated biopsies or polyp removals. I confirm I have completed the enema prep.

Signatures and Verification

Patient / LAR Signature

Physician Signature

Witness Signature

Date and Time of Consent

Document ID: CC-PENDING

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