Form Hh 577211 – Fill Out and Use This PDF

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Authorization for Flexible Fiberoptic Laryngoscopy

Patient’s Name: ___________________________________

I hereby authorize Dr._____________________________ to perform the following special

procedure/treatment:______Flexible Fiberoptic Laryngoscopy

Fiberoptic laryngoscopy is a way for your doctor to look at your voice box (larynx) as well as other nearby structures in your throat (pharynx). This helps your doctor see if there is any visible cancer. To do the procedure, a flexible tube about the width of a straw is put into the nose and threaded into the throat. The nose is usually numbed (anesthetized) before the tube is placed.

I understand that residents, medical students, physician assistants (PA) and/or advanced practice registered nurses (APRN) may also be in attendance, and/or assisting in the performance, and/or performing significant medical/surgical tasks within the above specified special procedure/treatment. In addition, I understand that there may be unforeseen circumstances that are encountered while performing the above listed special procedure/treatment that require the assistance of other qualified medical personnel who have not been identified.

I have had explained to me in connection with the proposed procedure/treatment: (i) the nature and purpose of the proposed procedure/treatment; (ii) the foreseeable risks and consequences of the proposed procedure/treatment, including the risk that the proposed procedure/treatment may not achieve the desired objective; (iii), the alternatives to the proposed procedure/treatment and the associated risks and benefits to such alternatives; and (iv) the reasonably foreseeable risks and alternatives to the transfusion of blood and blood products should I need a blood transfusion.

I have had explained to me that there are different ways to look at my larynx, including to have a laryngoscopy in the operating room, using the same scope or different scopes. I have had explained to me that this special procedure could be done in the future but have consented to have this done on date the physician and I agreed to after our discussion.

Specifically, in obtaining my informed consent to this special procedure, I have been informed of the following reasonably foreseeable risks:

•	Discomfort / pain	•	Bleeding	• Gagging
•	Sore throat	•	Inability to see well so that cancer is missed

•Allergic reaction to the numbing medicine that could cause life-threatening problems

•Extremely small chance of causing swelling of the voice box (larynx) that could make breathing difficult or impossible and that could require an emergency tube placed below the voice box (tracheostomy)

__________Patient initial

HH Forms 577211 N11/11 Printed by the Digital Print Center @ HH

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I am aware that, in addition to the reasonably foreseeable risks described above, there are other foreseeable risks, which have been discussed with me, but are not listed above. I affirm that I understand the purpose and potential benefits of the proposed treatment and/or special procedure, that no guarantee has been made to me as to the results that may be obtained, and that an offer has been made to me to answer any of my questions about the proposed procedure/treatment.

I also authorize the Hospital and the above-named physician(s) to photograph, video and /or use any other mediums which result in the permanent documentation of my image for medical, scientific or educational purposes, provided my identity is not revealed by them. I agree that any photographs taken pursuant to this authorization, which are not required by law to be retained, may be disposed of by the Hospital so long as the manner of disposition shall be permanent destruction.

This consent may be revocable by me at any time, except to the extent it has already been relied upon.

____________________________________M. D. Signed: ______________________________

	(Patient or legally authorized representative)
Date: ____________Time:__________	Date: ____________Time:__________

Interpreter responsible for explaining procedures and special treatment:

_________________________________________________ (Interpreter)

PATIENT UNABLE TO SIGN PRIOR TO SURGERY [ ฀ ] BECAUSE:

________________________________________________________________________________

_____________________________________ M.D.	Date: ____________Time:__________
_____________________________________ Witness	Date: ____________Time:__________

HH Forms 577211 N11/11 Printed by the Digital Print Center @ HH

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