Procedure Results and Biopsies from the Upper GI Endoscopy will only be discussed by Dr. Dave at the scheduled follow up office appointment.  Your child (the patient) must be present at the office visit and copayment will be collected at the time of the visit.

Your insurance will be verified and you will be called with all deductible and coinsurance amounts.  Payment is due 24 hours prior to the procedure or the procedure will be cancelled.  Changes made less than 48 hours prior to the procedure will incur a $75 service fee.

On the day prior to the procedure, the pediatric anesthesiologist and procedure facility will contact you directly to discuss any further instructions.  There will be separate charges from the anesthesiologist, procedure facility, and pathologist.

☐ Upper Endoscopy Instruction Sheet

Dr. Dave has recommended an Upper Endoscopy (upper scope).  This is a test in which the doctor looks directly into the esophagus, stomach, and upper small intestine with a narrow bendable tube, mounted with a camera and a light to help find out why children have abdominal pain, diarrhea, vomiting, or trouble growing.  The upper scope is done with your child under general anesthesia.  Your child will not be in pain and will not remember the procedure.  The doctor will take very small tissue samples (biopsies) that are the size of a pinhead, from the esophagus, stomach, and small intestine.  Biopsies do not cause pain.  Several biopsies are taken from each area.  Each biopsy site bleeds a little but the bleeding stops by itself.  Biopsies will tell us if there is acid damage, allergy cells, infections, ulcers, celiac disease, or Crohn's disease.  For the test, your child will not be able to eat or drink after midnight.  The upper endoscopy will take approximately 15 minutes.  You will arrive one hour prior to the procedure and will be discharged home approximately 30 minutes after the procedure.  Dr. Dave will speak with you very briefly after the procedure and a detailed discussion will take place at the scheduled follow up office appointment. I have read and understood the procedure instruction sheet:

Print Instructions

Signature of Parent/Guardian: _______________________________________________