Healthcare Larygo Form

HEALTHCARE LARYGO FORM

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical History & Current Health

Chronic Conditions (check all that apply):  Diabetes  Hypertension  COPD/Asthma  Heart disease

Procedure: Larygo

Procedure to be performed:

Intended therapeutic objective:

Risks, Benefits, and Alternatives

I acknowledge that the practitioner has explained the nature of the Larygo procedure, reasonably foreseeable risks and complications including but not limited to infection, bleeding, airway obstruction, voice change, aspiration, need for further procedures, anesthesia risks, permanent or temporary sensory or motor deficits, and uncommon but serious events including death. I understand that not all risks can be listed and that complications may require additional treatment.

I understand the expected benefits, which may include symptom relief or functional improvement, and that benefits cannot be guaranteed. Reasonable alternative treatments, including observation, medication, therapy, or alternative surgical techniques, have been explained to me and I have had the opportunity to ask questions.

Consent and Authorization

By signing this form I voluntarily authorize the provider and their designees to perform the Larygo procedure described above and to provide such associated medical care, monitoring, and anesthesia as deemed necessary. I authorize the use of photographs, video, or audio recordings for clinical documentation or treatment planning, with the understanding they will be used in the medical record and retained in accordance with facility policy.

I understand I may withdraw this consent at any time prior to the procedure by notifying the provider, except where withdrawal would jeopardize safety or where steps have already been taken that make withdrawal impracticable.

HIPAA Authorization / Release of Medical Information

I authorize the release and disclosure of my protected health information related to the Larygo procedure to other treating providers, insurers, and entities as necessary for treatment, payment, and healthcare operations. I understand this authorization is voluntary and that I may revoke it in writing except to the extent action has already been taken in reliance on this authorization.

Financial Responsibility

I accept financial responsibility for charges not covered by my insurer and understand that I am responsible for co-payments, deductibles, and any non-covered services. Payment policies, billing practices, and estimates have been explained to me and I have had the opportunity to discuss financial concerns prior to the procedure.

Patient Capacity and Representation

I certify that I understand the information provided and that I have had the opportunity to ask questions, which were answered to my satisfaction.

I am the patient and sign on my own behalf
I am the legal guardian or authorized representative signing on behalf of the patient

Acknowledgment and Affirmation

I acknowledge that no guarantee or assurance has been made by anyone about the results that may be obtained from the Larygo procedure. I have disclosed all known medical conditions and medications. I consent to the performance of the procedure and related treatments as described and authorize the release of my medical information as necessary for treatment and payment.

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