Informed Consent for Tonsillectomy and Adenoidectomy

AU Medical Center
Informed Consent for Surgical and/or Diagnostic Procedures

Date/Time:

1. I, , understand and acknowledge that I am to undergo the following procedure(s):

2. This procedure is to be performed by

I further understand that my physician may be assisted during this procedure by other physicians or practitioners whom he designates; and who may assist or perform portions of the procedure(s) at the request or under the direction of my physician.

3. I understand that the purpose of this procedure is:

4. I understand that this procedure involves certain risks. These may include risk of infection, allergic reaction, disfiguring scar, severe loss of blood, loss of function of any limb or organ, paralysis, brain damage, cardiac arrest, or death. In addition to these risks, there may be other possible risks as a result of this procedure, including, but not limited to:

5. I acknowledge and understand that during the course of the procedure(s) described above, it may become appropriate to perform additional procedures which are unforeseen or not known to be needed at the time this consent is given. Therefore, I hereby consent to and authorize AU Medical Center (AUMC), its medical staff and those other medical personnel selected by AUMC to make decisions concerning the performance of such procedure(s) as they deem reasonably appropriate in the exercise of their professional judgment. This consent shall also extend to the treatment of all conditions which may arise during the course of such procedures including those conditions which may be unknown or unforeseen at the time this consent is given. If conditions permit, an attempt to notify an authorized family member of changes occurring in the operating room will be made.

6. I understand that if I do not undergo this proposed procedure(s), my prognosis is:

7. I understand that the practical alternatives to this procedure include:

8. I authorize AUMC to dispose of any severed tissue, organs, or body parts in accordance with the law and with AUMC policies.

9. I also consent to diagnostic studies, tests, anesthesia, x-ray examinations and any other treatment or courses of treatment relating to the diagnosis or procedures described herein. A separate informed consent document may be required prior to some of these procedures.

10. If a medical device is implanted in me, I authorize AUMC to provide the manufacturer of such implanted device with my name, address, telephone number, and social security number for implant tracking purposes.

11. I understand that AUMC is an academic medical center with education as an integral part of its mission. Consequently, I authorize the presence of students and other observers for educational purposes during my procedure.

12. I authorize the taking and publication of photographs or films (including videotape and television monitoring) of the procedure(s) subject to the following conditions: a. that said photographs, films, or video be used only for purposes treatment and/or for the purposes of education and research both internal and external to AUMC, and b. that the above described use and disclosure may continue without expiration except and unless I rescind authorization for such use and disclosure in writing, and c. that the name of neither me nor my family will be used to identify said photographs, films, or videotapes.

13. I understand that I have the right to ask questions and I hereby certify that I have been given the opportunity to ask questions and that any such questions have been answered or explained to my satisfaction.

14. I understand that no guarantees, assurances, or promises have been made to me concerning the results of this procedure.

Page 2 Consent

For Procedure(s):

15. By signing this form, I acknowledge that I have read it carefully or had it read or explained to me and that I understand this form and its contents, and I hereby voluntarily consent to and request AUMC, its medical staff, and all other medical personnel which may otherwise be involved in my treatment to perform the procedure(s) described or otherwise referred to herein. (This consent will be valid for thirty (30) days from date of signature unless revoked.)

TELEPHONE CONSENT (if applicable)

When a telephone consent is being obtained, the above information must be read to the person consenting.

I, , read the above information to at Date/Time:

states that he/she is of and he/she authorized the treatment/procedure described above and has been provided an opportunity to ask any desired questions.

Practitioner’s Signature/Title: Date/Time:

I witnessed and overheard the telephone conversation in which the above consent was given to perform the desired treatment/procedure.