Name: __________________________       Today’s date        _____ / ____ / 2007

PARQ (Procedure, Alternatives, Risks & Questions) conference

Procedure: Microlaryngoscopy with

__ Excision

__ Injection

__ Other  ________________

__ with CO2 laser

Anesthesia: General

Case Time    1 hour   1 1/2 hours     2 hours

Preferred Date of Surgery:  _____ / ____ / _____    ASAP,      at patient convenience

Alternatives: might include speech therapy or no treatment

Risks: Anesthesia risk, chipped tooth, numb tongue, suboptimal result, laser burn

Laryngoscopy means inserting a metal tube in the throat to view the voice box. The main risks of surgery include, but are not limited to a reaction to anesthesia, which is uncommon but can be life threatening. The procedure can uncommonly cause a chipped tooth. More common is a numb tongue for a few days to several weeks after the procedure. In my experience this usually resolves. If a laser is used, the risk includes a possible burn by the laser in an area other than intended. Results with surgery cannot be guaranteed and a sub-optimal result is possible. There is an extensive explanation of the procedure available in print from the office or at http://old.voicedoctor.net/surgery/mxlx.html on the internet.

Students may be involved in observing or assisting with procedures described above. Their name(s) are _________________________________________________________________________. They may be involved in removing some portion of the lesion safely. ____ Patient's initials

All the above was explained to me. I have seen the extensive explanation and my questions have been answered to my satisfaction.

 

_________________________________     ____ / ____ / ____

   Patient signature                       Date

 

_________________________________

   Witness

 

_________________________________     ____ / ____ / ____ 

   James P. Thomas, MD                   Date          

 

Preferred hospital

Legacy Emanuel | Providence | Futures