Date of Test:(Required) MM slash DD slash YYYY Time:(Required) Hours : Minutes AM PM AM/PM Gastric Emptying Study Instructions: Nothing to eat or drink for 4 hours prior to the exam. Wear comfortable clothes and shoes. You may continue your normal medications, which could be taken with a small amount of water or juice up to four hours prior to your study. Some medications are generally stopped for this test. This should be discussed with Dr. Suleman prior to the test. Drugs that affect gastric emptying such as Reglan® (metoclopramide), Zelnorm® (tegaserod), erythromycin, and Motilium® (domperidone) and antispasmodics such as Bentyl®, Donnatal®, Levsin®, and Robinul® are usually stopped for three days prior to this test. Do not take any laxatives on the day before or any time during your study. This exam will take around 3-4 hours. You will be able to drive afterwards (If you are able to drive yourself). Please call (214) 504-9942 if you have any questions regarding this procedure. Consent for Gastric Emptying Study: A gastric emptying study is a procedure that is done by nuclear medicine technician and physician using radioactive chemicals that measures the speed with which food empties from the stomach and enters the small intestine. You will eat a solid component of the meal (for example, scrambled egg), a liquid component of the meal (for example, water), or both, mixed with a small amount of radioactive material. A scanner is placed over your stomach to monitor the amount of radioactivity in the stomach for a few hours after the test meal is eaten. Female Patient Screening (applicable to females that are 11-55 years of age): Is there any possibility you could be pregnant? Yes No If "NO", please check appropriate: Had a hysterectomy, tubal ligation, or post- menopausal? Currently on birth control? Your last menstrual cycle start within the last 14 days? When was the date of your last menstrual period Are you currently breast feeding? Yes No No Show Responsibility:The HIDA involves us ordering dye that must be opened before you arrive. If you do not show up for this appointment, the medication will be unusable. Please give us 24-hour notice if you will not be able to make the appointment. If you do not show up for this appointment and no notification is received within 24 hours prior to the test, then we will be billing you for the cost of the nuclear medication ordered. The total cost of medication is $50. Please let us know if you have any questions regarding this policy. **PLEASE NOTE, IF YOU HAVE MEDICAID OR ANY MEDICAID MANAGED CARE PLAN, THEY WILL NOT COVER THE DRUG FOR THIS TEST AND YOU WILL BE RESPONSIBLE FOR THE $50.00 UP FRONT**I have read and understand the above information.Patient Name: Patient SignatureWitnessDate MM slash DD slash YYYY Δ
