Informed Consent for Tonsillectomy and Adenoidectomy
Introduction
This information is given to you so that you can make an informed decision about
having tonsillectomy and adenoidectomy. Take as much time as you wish to read this
information and ask questions of your doctor or the assistants. You have the right to ask
questions about and understand the surgery as well as you can before deciding to have the
surgery. After learning of your condition and your options for treatment, you and your
doctor are the ones who decide together if and when you should have this operation based
on your needs and medical condition. This surgery is not an emergency. You may
decide not to have this operation at all.
Nature of the Condition and Treatment
Except in unusual circumstances, tonsillectomy and adenoidectomy is appropriate when
you have chronic tonsillitis, obstructive sleep apnea, or enlarged tonsil and adenoids
causing problems with sleep, swallowing, sinus drainage, nasal breathing, or bad breath.
If you choose to have tonsillectomy and adenoidectomy, it is important to understand that
your tonsils (at the back of the mouth on both sides) and possibly your adenoids (at the
back of the nose) will be permanently removed.
1. Complications of Surgery in General: As with all types of surgery, the
possibility of other complications exists due to anesthesia, drug reactions or
other factors which may involve other parts of my body, including a
possibility of brain damage or even death. The likelihood of these
complications is very low. The benefits of decreased infections and improved
sleep and breathing from successful surgery are significantly greater than the
possibility of a complication noted below.
2. Specific Complications of Tonsillectomy and Adenoidectomy: Risks
include bleeding (potentially life-threatening) at time of surgery or after
surgery (typically one week after), post-operative infection, severe pain,
dehydration, loss of airway, pulmonary edema (fluid in lungs), need for
hospitalization, unusual scarring of soft palate and back of mouth,
velopharyngeal insuffiency (problems sealing off the back of the nose causing
voice and swallowing problems), damage to lips and teeth, and need for
further procedures.
Alternative Methods of Treatment for Chronic Tonsillitis and Adenotonsillar
Enlargement
Alternative treatments for this condition are antibiotics when infected, steroids to
decrease enlargement, airway support during sleep such as CPAP, and other techniques.
Patient Statement and Consent for Operation
I hereby authorize Matthew C. Jepsen, MD , and any associates or assistants of
his choice to perform upon me tonsillectomy and adenoidectomy.
I recognize that during the course of the procedure, unforeseen conditions may
necessitate additional or different procedures than those explained. I, therefore, further
authorize and request my doctor and any associates or assistants of his choice perform
such as are, in their professional judgment, necessary or appropriate for such procedures.
I understand that the proposed care may involve risks and possibilities of
complications, and that certain complications have been known to follow the procedure
to which I am consenting even when the utmost care, judgment and skill are used. I
acknowledge that no guarantees have been made to me as to the results of the procedure,
nor are there any guarantees against unfavorable results.
I accept the risks of substantial and serious harm, if any, in hopes of obtaining
desired beneficial results of such care and acknowledge that the physicians involved have
explained my condition, the proposed health care, and alternative forms of treatment in a
satisfactory manner.
The basic procedures of the proposed surgery, the advantages, disadvantages,
risks, possible complications, and alternative treatments have been explained and
discussed with me by my doctor. Although it is impossible for the doctor to inform me of
every possible complication that may occur, the doctor has answered all my questions to
my satisfaction. In signing this consent form, I am stating I have read this form (or it has
been read to me), and I fully understand it and the possible risks, complications and
benefits that can result from the surgery. I also acknowledge that the doctor has
addressed all of my concerns regarding this surgery.
Patient’s Name: Age
Patient’s Signature:
Date: Time: Place:
Witness’ Signature:
Doctor’s Signature:
As parent, guardian, caretaker, next of kin or other legal representative responsible for the
patient whose name appears above on the appropriate patient signature line, I have read
this document and, to the limit of the patient’s understanding, I have discussed this
informed consent and its terms with the patient. Due to the patient’s inability to sign this
informed consent, I agree, on behalf of the patient, to sign for the patient and bind
him/her to the terms of this informed consent.
Name: (printed)
Signature:
City: State: Zip:
Relationship to Patient:
Date: Time: Place:
I have received a copy of this informed consent for my own records. I have had the
opportunity to read this informed consent and my questions regarding the
surgery, alternatives, risks, and expected outcomes have been answered.
Signature:_______________________________________________________________
Name: (printed)___________________________________________________________
Patients Name: ___________________________________________
NOTE: You need to make a choice about receiving these health care items or services.
Your insurance company may not pay for the item(s) or service(s) that are described
below. Insurance companies only pay for covered items and services when insurance
company rules are met. The fact that your insurance company may not pay for a
particular item or service does not mean that you should not receive it. Right now, in
your case, your insurance company may not pay for –
Items or Services:
T&A
Because:
Your Deductible
Patient Responsibility
Not covered with your contract
Out of network doctor or facility
Pre-Existing condition
Elective or cosmetic surgery
The purpose of this form is to help you make an informed choice about whether or not
you want to receive these items or services, knowing that you might have to pay for them
yourself. Before you make a decision about your options, you should read this entire
notice carefully.
- Ask us to explain, if you don’t understand why your insurance company may
not pay.
____Option 1. YES. I want to receive these items or services.
I understand that my insurance company will not decide whether to pay unless I receive these items or
services. Please submit my claim to my insurance company and understand that you may bill me for items
or services and that I may have to pay the bill while the insurance company is making the decision. If my
insurance company does pay, you will refund to me any payments I made to you that are due to me. If my
insurance company denies payment, I agree to be personally and fully responsible for payment. That is, I
will pay personally either out of pocket or through any other insurance that I have. I understand I can
appeal the insurance company decision.
____ Option 2. NO. I have decided not receive these items or services.
I will not receive these items or services. I understand that you will not be able to submit a claim to my
insurance company and that I will not be able to appeal your opinion that my insurance company will not
pay.
____________________ _________________________________________
Date Signature of patient or person acting on patient’s behalf
