Informed Consent for
ENDOSCOPIC SINUS/NASAL SURGERY
(Approved by All India Rhinology Society)
son/daughter/wife of:
Age &sex:
Reg.No.:
Address
PLEASE READ THIS DOCUMENT CAREFULLY AND ASK ABOUT ANYTHING YOU DO NOT FULLY UNDERSTAND. AFTER YOU HAVE READ IT, PLEASE SIGN FOR THE SURGERY OR PROCEDURE.
1. I have spoken to the doctor (s) who has/ have explained that I/my have/ has (condition/symptoms/provisional diagnosis)
2. What might happen to me/my if we do not treat this condition has been explained to me. The different ways to treat the conditions and the advantages and disadvantages of each of these was discussed with me. The Doctor has informed me that my problem may have arisen as a consequence of an allergy and has accordingly asked me to be treated for it as the surgery itself is only a part of the treatment.
3. The doctor wants (suggested) me/ my to have the following operation (s) or procedure (s): ESS/Septal Surgery/Turbinate Surgery
4. The doctor talked to me about how this surgery or treatment might help me. The doctor explained that the treatment might change if there was a change in my condition or if they find something different during treatment. The doctor also told me about how long it would take me to recover.
5. I am fully aware that the treatment/ surgery/ procedure is being performed in good faith and no guarantee/ assurance has been given as to the result that may be obtained. The doctor gave me an opportunity to ask questions about my condition and different ways to treat it.The doctor answered my questions. I am satisfied with the answers about my treatment.
6. I have been fully explained that there can be risks, complications or side-effects about any operation or medical procedure or anaesthesia. I know the doctor cannot tell me about every possible risk, complication or side-effect. We did talk about the major ones (for example : bleeding, infection, pneumonia, heart complications, blood clots, risk to life) that could happen if I have the operation or procedure. However the chances of these major complications are very rare. One to two percent of the patients can have bleeding which may require controlling it under anesthesia.
7. The doctor also explained me about these other risks :severe bleeding possibly requiring transfusions and possibly leading to stroke and/or death, bleeding into the eye and/or brain requiring external incisions for drainage, persistent nasal crusting, persistent tearing and/or damage to the tear ducts, damage to the nasal septum including hole formation in the septum, numbness and/or chronic pain to the forehead, face, and/or teeth, new or persistent infection with possible spread or infection to form brain infection or abscess, loss of or damage to sense of smell and/or taste, eye infection or abscess, and infection in distant spots of the body, damage to the eyes including permanent blurred vision and/or blindness, brain damage including damage to the lining of the brain, temporary or permanent scarring of the sinuses, with brain fluid leak, the need for further sinus, eye, or brain operations including operations that lead to external scarring, heart attack, stroke and/or death, and other unanticipated risks. Again these complications are extremely rare.
8. The doctor gave me a chance to ask questions about these risks and any other risks I wanted to know about. The doctor answered my questions. lam satisfied with the answers about the risks.
9. The doctor has explained to me that the doctor or whosoever may be designated as assistant may be doing important tasks related to surgery or procedure under the direction of the doctor.
l0 This surgery will be performed under local/ general anaesthesia.The doctor has explained to me about the general/complications of drug interactions, blood transfusion and risk to life.
11. If something unexpected happens or is found during the procedure or operation, that in the doctors opinion. Pose an immediate and substantial risk to my health and needs treatment in addition to or different from what is described above, also agree that the doctor (s) may at that time provide the treatment that is immediately necessary.
12. In the event of any systemic complications, I authorize the doctor (s) to transfer the case to an appropriate medical centre for necessary treatment.
13. Any tissues or parts surgically removed may be sent for examination/disposed off in accordance with accustomed practice.
14. I consent to pictures or videos being recorded or televised during my treatment for medical, research or educational purposes, as long as my identity is not shared.
l0 This surgery will be performed under local/ general anaesthesia.The doctor has explained to me about the general/complications of drug interactions, blood transfusion and risk to life.
11. If something unexpected happens or is found during the procedure or operation, that in the doctors opinion. Pose an immediate and substantial risk to my health and needs treatment in addition to or different from what is described above, also agree that the doctor (s) may at that time provide the treatment that is immediately necessary.
12. In the event of any systemic complications, I authorize the doctor (s) to transfer the case to an appropriate medical centre for necessary treatment.
13. Any tissues or parts surgically removed may be sent for examination/disposed off in accordance with accustomed practice.
14. I consent to pictures or videos being recorded or televised during my treatment for medical, research or educational purposes, as long as my identity is not shared.
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