Forms

INFORMED CONSENT FOR MEDICAL OFFICE PROCEDURES AND TREATMENT

The physician and staff of ENT Associates of SW Georgia, LLC are pleased that you have selected us to help you with your health concerns. The information you provide for us and the examinations and tests performed are all used to determine the most likely diagnosis of your problem. The diagnosis may be difficult to determine at first as many problems present in a similar manner. Tests that are more difficult to perform and may have the possibility of complication are usually not recommended until they are necessary to help determine the cause of your problems.

The treatments are selected to help you cure or improve your health problems. No treatment is 100% effective for all patients and all treatments have some potential for complications. We try to select the best treatment with the least potential for complications. Many of the treatments are selected from successful experience in using them. Others are recent improvements that have been successful in medical trials. It is not uncommon for physicians to prescribe different therapies for the same condition and get essentially identical results. There are alternative treatments for some problems, such as herbal remedies or acupuncture, in which the physician may have limited experience or the medical studies may be inadequate or contradictory such that the physician would not recommend these as first choice of treatment.

It is important to understand that complications can occur with even the simplest treatment. Anything that enters the body has the potential of a very serious reaction. Some people will die from a bee sting or just eating a peanut if they have a serious allergy to either of these. Unfortunately, no one knows if they have allergies to any food, drugs or other chemicals until they have a reaction. If these reactions are severe, they will cause rash, swelling and sometimes difficulty breathing. Therefore, it is important to inform your physician of any and all adverse medication reactions that you have experienced in the past. It is also very important to tell your physician and pharmacist all medications that you are currently taking because some medications may react with other medications in a bad way.

If medication reactions occur, seek medical help. If severe swelling or shortness of breath or wheezing should occur one should go to the nearest medical emergency facility and even call 911, if necessary. Do not take any more of the medication and be sure to tell the prescribing physician and pharmacy that filled the prescription about the reaction. Any type of medications (pills, liquids, creams, suppositories, injections) can cause reactions. You should also read information provided by your pharmacist about medications you have been prescribed.

Examples of some precautions needed for medications are:

~Do not stay in the sun for very long while taking certain prescriptions

~Many prescriptions should not be taken if you are pregnant or possibly pregnant. It is very important to advise anyone prescribing a medication or performing tests or treatment for you if you are pregnant or possibly pregnant.

Many medications may cause mild nausea or upset stomach. Serious N/V or diarrhea needs attention and you should advise the prescribing doctor about this problem. If you develop diarrhea while taking an antibiotic, discontinue the antibiotic and notify your physician.

Immunizations are made from the virus or bacteria that cause the illness you are trying to avoid. You may notice “flu-like” symptoms that may be very uncomfortable for a few days. Rarely an un-predictable severe reaction may occur and cause a significant medical problem or even death. This risk is recognized as the only way large numbers of people can avoid these diseases that can also be very serious and even lead to death.

Some medications can affect blood counts, kidney and liver function or other organ functions, which may not show up early in the course of treatment. Lab tests or other tests may be ordered from time to time to monitor for these possible toxicities. It is very important that you follow through and complete all tests as recommended.

Anything that penetrates the skin, such as a shot, injections, biopsy or surgical incision may have complications such as:

~An infection under the skin first noticed as redness and tenderness that spreads.

~Bleeding that may cause a bruise or blood clot under the skin. This will absorb and go away in time. If the blood clot becomes infected it will become increasingly tender and warm and redness will spread.

~Continuous bleeding may be seen from the incision or it may begin to swell within a couple of hours following the procedure. Apply pressure on the bleeding or swelling

~An injury, such as to a nerve, that could cause a loss of sensation or decrease in muscle tone. It is likely that nothing can be done to remedy this complication.

In all cases, notify your physician. It the prescribing physician is not available, other physician or members of the office staff will be able to assist you when you call. Indicate that this is a medical problem from a treatment or procedure. If it is after business hours or on the weekend, go to the emergency room if the problem is urgent. You can get in touch with your physician or the on-call physician by calling the hospital operator at 229-228-2000.

This information is provided to help you decide if you wish to receive the treatment or tests recommended with the knowledge of these potential complications. By signing this form you are giving your consent and permission for the physician and staff to prescribe and perform treatments and tests they recommend for your health needs. This informed consent will be kept on record and considered active for all treatments following the date of your signature. This will apply to any treatments and recommended tests should they occur in this office, as a result of a phone call from you or at the hospital or emergency facility when any physician or one of the staff of this office provides the service. A copy will be provided for you at any time upon your request.

You always have the right to not take any prescription or refuse any procedure or test even if you have previously consented to it. The alternative for not accepting the treatment prescribed and doing nothing is that the condition may get worse, stay the same or possibly get better on its own. As mentioned before, there usually are alternative treatments available for your particular problem.

Lastly, a copy of your medical records (paper copy or electronic) is available to you, at your request.

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I have read or have had read to me this informed consent. I have had an opportunity to ask questions regarding this consent and any potential benefits or complications that can result from treatments or tests ordered by my physician. I understand the information in this informed consent.

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Signature of Patient or Guardian Print Patient Name Date

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Witness Signature Date