GI Consent
GnuBaØat[BinitüemIleraK BüaáleraKenApøÚvGahareTAdl´TVarFM

Endoscopy informed consent
karRáb´ GnuBaØat[Binitüftqøú¼emIleraKenAxagkñúg

Patient Name
eQµa¼GñkCm¶W

DOB.
éf¶ExqñaMekIIt

Today’s Date
éf¶ExqñaMen¼

I authorize Doctor and other assistants or health care providers as he or she decides are necessary, to perform the following procedures.
xJúMGnuBaØat[evC¢bNÐit ¬RKÜeBTüehIynwgGñkCMnYyeBTßRbús ¬RsI ¬k_GñkCYybMerIxJúMenAkñúgeBlcaMác´epßgeTot edIm,InwgeFVIkarBinitütamdanemIleraK ¬karv¼kat´[xJúM /treatment BüaáleraKxJúM.

Colonoscopy                                                       Small Bowel Enteroscopy
karftqøú¼edIm,InwgBinitüemIlkñúgeBa¼evonFM            karftqøú¼edIm,InwgBinitüemIlkñúgeBa¼evontUc

Esophagogastroduodenoscopy                        pH Test, 48-hour
karftqøú¼emIlenAkñúgbMBg´k RkB¼ ehIynwgk,aleBa¼evontUc BIesaFn_emIlTwkGasIud24em¨ag  

Flexible Sigmoidoscopy                                    Other:
eBa¼evonFMEpñkxageRkamragdUcGkßrEGs             epßgeTot

To view all translations and download the entire file, please click the bottom below to purchase.

ebIcg´ánÉksarbkERbCaExµrTaMgGs´en¼emIl sUmcuCenAxageRkamen¼ vamantémø

$1.50