POTENTIAL INDICATIONS:
1. Precise diagnosis of organic lesions of the larynx, particularly of those parts of the larynx which difficult to examine, and removal of a biopsy specimen for histology.

2. Drainage of abscesses and cysts, etc.

3. Complete removal of benign lesions from within the larynx, possibly with the laser.

4. Removal of local edematous swellings.

5. Removal of scars, strictures, synechiae, and webs, possibly with the laser.

6. Procedures to improve function in vocal cord paralysis and vocal cord defects.

POSSIBLE ADVERSE EFFECTS:
Known potential adverse effects include:

1. Bleeding

2. Infection

3. Hoarseness from scar tissue formation

4. Injury to teeth

5. Temporary alternate airway access with tracheotomy

6. Adverse effect associated with general anesthesia

I/We have been given an opportunity to ask questions about my condition, alternative forms of treatment, risks of nontreatment, the procedure to be used, and I/we have sufficient information to give this informed consent.

I/We certify this form has been fully explained to me/us, and I/we understand its contents. I/We understand every effort will be made to provide a positive outcome, but there are no guarantees.

_______________________________ ________________________________
Patient / Legal Guardian Witness
Date:__________________________
Time:___________________________