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Free ERCP Consent Form Template

Operational & Compliance DisclaimerDisclaimer: This template is a sample for operational and administrative purposes only. ConsentCollect is a software platform, not a law firm or a healthcare provider. Consult with qualified legal counsel and medical directors to ensure compliance with local regulations before deploying any clinical consent form.

Professional medical consent form template for ERCP

Informed Consent for Endoscopic Retrograde Cholangiopancreatography (ERCP)

Patient Informed Consent Documentation

Patient and Procedure Information

Facility Name

Performing Gastroenterologist

Patient Full Legal Name

Date of Birth

Medical Record Number (MRN)

Date of Procedure

Anesthesia/Sedation Plan

Procedure Indication

Nature and Purpose of the Procedure

Endoscopic Retrograde Cholangiopancreatography (ERCP) is an advanced specialized procedure used to examine and treat conditions of the bile ducts and pancreatic ducts. An endoscope is passed through your mouth, esophagus, and stomach into the duodenum. A small plastic tube (catheter) is then threaded through the scope and into the opening where the bile and pancreatic ducts drain (the papilla). A liquid contrast dye is injected, and X-ray images (fluoroscopy) are taken to visualize stones, blockages, or narrow areas. If abnormalities are found, therapeutic interventions may be performed during the same procedure: (1) Sphincterotomy: cutting the small muscle of the duct opening to allow stones to pass or improve drainage, (2) Stone extraction: using a balloon or basket to pull stones from the duct, (3) Stent placement: inserting a plastic or metal mesh tube to keep a narrowed duct open, (4) Biopsy or brush cytology: collecting cells or tissue samples for analysis.

Therapeutic Intervention Authorizations

I authorize the physician to perform a sphincterotomy (cutting the muscle opening of the bile/pancreatic duct) if needed to extract stones or place drainage stents.

I authorize the placement of temporary or permanent biliary or pancreatic stents (plastic or metal mesh tubes) to relieve duct blockages.

I authorize the removal or replacement of existing stents if present.

I authorize tissue biopsies, fluid aspirations, or brush cytology for diagnostic pathology analysis.

Material Risks and Potential Complications

Post-ERCP Pancreatitis: inflammation of the pancreas, which is the most common complication of ERCP. It occurs in 5 to 10 percent of patients. While most cases are mild and resolve with 2 to 3 days of hospitalization, severe pancreatitis can lead to organ failure, prolonged intensive care, or death. The physician may place a pancreatic stent or administer rectal medication at the end of the procedure to reduce this risk.

Infection (Cholangitis/Cholecystitis): infection of the bile ducts or gallbladder can occur if bile drainage is not fully restored. Antibiotics are given before and sometimes after the procedure to reduce this risk.

Bleeding: occurs in 1 to 2 percent of cases, almost always related to a sphincterotomy cut. It is usually controlled during the procedure, but delayed bleeding can occur up to 2 weeks later, requiring hospital admission or a blood transfusion.

Perforation: a tear or hole in the esophagus, stomach, duodenum, or bile duct. This occurs in less than 1 percent of cases. A perforation is a serious complication that often requires immediate surgical intervention to repair.

Radiation exposure: the procedure uses X-ray imaging. The dose of radiation is kept as low as possible. Female patients must report if there is any chance of pregnancy.

Sedation and anesthesia risks: breathing problems, drop in blood pressure, or adverse drug reactions. Anesthesia providers monitor your vitals continuously.

Surgical Backup Acknowledgment

Because ERCP is an invasive therapeutic procedure, serious complications such as perforation, uncontrolled bleeding, or severe infection can occur. I understand that if a complication arises that cannot be managed endoscopically, emergency transfer to a surgical team and immediate abdominal surgery (laparotomy) may be required. I authorize the clinical team to initiate such emergency measures if determined necessary to preserve my safety.

Alternatives to ERCP

Magnetic Resonance Cholangiopancreatography (MRCP): a non-invasive MRI scan of the ducts. Can diagnose issues but cannot perform therapeutic actions (e.g. cannot remove stones).

Endoscopic Ultrasound (EUS): a specialized endoscope using sound waves to view the ducts from inside the stomach. Used for diagnosis; cannot perform most duct interventions.

Percutaneous Transhepatic Cholangiography (PTC): a radiologist inserts a needle through the skin of your abdomen into the liver to drain bile or clear stones. An alternative if ERCP cannot be completed.

Open or laparoscopic surgery: direct surgical exploration and clearing of the bile ducts.

Pre-Procedure Requirements

You must not eat any solid food for at least 8 hours and must not drink clear liquids for at least 4 hours before the procedure. You must tell your doctor about all blood thinners (aspirin, Plavix, Coumadin, Eliquis) you take. These must be stopped for a specified number of days before the procedure to minimize bleeding risks during sphincterotomy.

Post-Procedure Warning Signs

You must seek immediate emergency medical care if you experience: (1) Severe, sharp, or worsening pain in your abdomen or back, (2) Fever or chills, (3) Nausea and vomiting that does not stop, (4) Black, tarry stools or blood in your stool, (5) Dizziness, fainting, or weakness, (6) Yellowing of your skin or eyes (jaundice).

Discharge Driver Requirement

You will receive deep sedation or general anesthesia. You are required to have a responsible adult driver accompany you to the facility, remain during the procedure, and drive you home. You must not drive or make critical decisions for 24 hours after the procedure.

Right to Withdraw Consent

You have the right to refuse the ERCP procedure. The physician will discuss the risks of untreated duct blockages, which include severe infection (cholangitis), liver damage, pancreatitis, and worsening jaundice.

Patient Understanding and Questions

I confirm that I have read this document and understand the ERCP procedure, its benefits, risks, and alternatives. I have had my questions answered to my satisfaction. I understand that ERCP has specific risks, including pancreatitis and perforation, and I consent to proceed.

Language Access

If English is not your primary language, a qualified medical interpreter is available to assist you at no cost. Please notify the facility before signing.

Copy of Consent Acknowledgment

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

Patient Authorization

I voluntarily consent to undergo Endoscopic Retrograde Cholangiopancreatography (ERCP) and the therapeutic interventions (sphincterotomy, stone extraction, stent placement, or biopsy) determined necessary by the physician. I confirm I have followed all pre-procedure fasting and medication guidelines.

Signatures and Verification

Patient / LAR Signature

Gastroenterologist Signature

Witness Signature

Date and Time of Consent

Need to print or customize this template?

Download a clean PDF copy or customize it in our Free Consent Builder. No account required.

Looking for a complete clinical workflow?

Standard PDF consent forms still leave your practice exposed to malpractice disputes. If you want verified patient comprehension quizzes, automated signing order tracking, biometric signature seals, and direct Epic/Cerner EHR FHIR R4 integration, then upgrade to our full ConsentCollect App.

Free Document Schema Specifications

Template Classification:ERCP Layout

Target File Format:Printable PDF / HTML Structure

Customization Capability:Fully Editable Text & Checklist Fields

Licensing & Rights:Free Personal & Practice-Wide Use

How to Use the Digital ERCP Consent Template

The ERCP document layout available on this page is a structured administrative schema designed for gastroenterology practice managers, compliance coordinators, and healthcare operations teams. Informed consent form layout for ERCP procedures, covering fluoroscopic contrast injection, pancreatitis risk disclosure, sphincterotomy and stent placement authorizations, and emergency surgical backup fields for clinical compliance workflows.

Using the ConsentCollect Free Builder, administrative staff can import this ercp schema and configure every field to match their specific facility requirements. The builder supports drag-and-drop field reordering, custom label editing, signature block layout control, and client-side PDF generation, with no coding knowledge required and no account needed.

Once the ercp layout is finalized, it can be printed as a high-resolution paper document, embedded into a digital patient intake kiosk, or exported as a structured JSON payload for integration into an existing EHR or practice management system. Organizations running the full ConsentCollect App subscription gain access to verified comprehension tracking, automated signing sequence management, biometric signature seals, and FHIR R4 interoperability with Epic and Cerner platforms.

❓ Frequently Asked Questions

How do I import and configure this ERCP document layout in the Free Builder?

Click the "Customize in Free Builder" button on this page. The form schema opens directly in the client-side ConsentCollect Free Builder canvas with all fields, sections, and signature blocks pre-loaded. You can then drag and drop additional fields, relabel any section header, swap placeholder text for your facility name and provider credentials, and rearrange the field order to match your clinic workflow, all without creating an account.

What document structure and field types does this ERCP layout include?

This layout contains 15 structured sections covering patient identification fields, administrative intake data, and signature capture blocks. Practice managers and compliance officers can override any field label or placeholder value inside the builder to match their own intake schema.

Can I use this ERCP template for my Gastroenterology practice without a paid subscription?

Yes. The Free Advanced Form Builder is entirely public with no account required. You can open this ercp layout, edit all fields, and export a print-ready PDF or copy the underlying JSON schema at no cost. A paid ConsentCollect App subscription unlocks additional workflow features such as encrypted transmission, timestamped audit logs, multi-party signing order, and direct FHIR R4 EHR integrations.

Does this page provide clinical, legal, or medical advice about ercp procedures?

No. This page is an administrative document schema tool hosted by ConsentCollect, a B2B compliance software platform. The form layout is provided for operational and administrative configuration purposes only. ConsentCollect is not a law firm, healthcare provider, or clinical advisory service. Before deploying any consent document to patients, the finished form must be reviewed by your organization's qualified legal counsel and a licensed medical director to confirm compliance with applicable regulations in your jurisdiction.

How do I export, print, or integrate this ERCP form schema into my EHR system?

After editing in the Free Builder, use the Export button to download a high-resolution PDF suitable for physical signature collection. Alternatively, copy the JSON schema payload for use in your own patient intake database or web application. Subscribers to the full ConsentCollect App can push finalized templates directly into Epic or Cerner workflows via a certified FHIR R4 integration layer without any manual re-entry.

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