For Patients and Referring Physicians
To assist ASGE members in their practice and in educating their patients who’ve had a polyp removed during colonoscopy, ASGE has created polyp information sheets that explain what a polyp is and when patients should return for a follow-up exam. The Society has also created a sheet to send to the patient’s referring physician so that they are aware of the results of the patient’s exam and when it is recommended that the patient return for a follow-up colonoscopy.
Following are links to the three polyp sheets, which are easily downloadable. You may choose to print hard copies to write on manually or you may fill in the gray shaded boxes electronically. In addition, at the top of each polyp sheet is a placeholder to insert your facility’s logo.
Each sheet is two pages in length; It is best to print double-sided so that the patient/physician has just one sheet of paper to retain.
Note to Physicians
Do not download these forms unless you agree to the following terms.
- By downloading these forms, you are agreeing to hold ASGE harmless against any costs, claims, damages, and expenses, including attorney fees, arising from the use of these forms.
- You are also agreeing not to modify any of the educational content provided by ASGE in these forms.
- You may modify the “blank” sections to communicate the patient’s exam results and to insert your facility’s logo at the top of the forms where indicated.
If you have any questions about the use of these forms, please email email@example.com.
Polyp Sheets for Patients:
Basic Polyp Information Sheet
This sheet is to be handed to the patient before they leave the doctor’s office after they’ve had a colonoscopy. It contains basic information about polyps and includes a section for the preliminary results of the patient’s exam to be noted. Download the Basic Polyp information sheet
Post-Pathology Information Sheet
This sheet is to be mailed to the patient with the formal polyp pathology results and provides a recommended follow-up exam date based on the pathology results. This sheet contains more detailed information on polyps, why follow-up exams are important and advises the patient to speak to family members about getting screened for colon cancer. Download the Post-Pathology Patient Information Sheet.
Polyp Sheet for Referring Physician:
Information Sheet for Referring Physician
This sheet is to be mailed to the patient’s referring physician after the pathology results are received and provides a recommended follow-up exam date for the patient based on the pathology results. In addition, the sheet contains more detailed information on polyps, why follow-up exams are important and advises the referring physician about family members at risk including a reference to the ASGE guideline on CRC screening and surveillance. Download the Policy Information Sheet for Referring Physician..
Additional Polyp Information Sheet for Use by Referring Physicians:
To assist referring physicians in educating their patients who’ve had a polyp removed during colonoscopy, this polyp information sheet explains what a polyp is and provides general information on follow-up exams. Members are encouraged to use this sheet as an outreach tool to their non-GI colleagues to promote colorectal cancer screening and surveillance. Download the Additional Polyp Information Sheet for Use by Referring Physicians.