I hereby authorize Robert L. Fischer, M.D. to treat the following condition(s):

INFECTION OR FLUID COLLECTION OF MIDDLE EAR COMPARTMENT BEHIND EAR DRUM

The procedures planned for the treatment of my condition(s) have been explained to me by my physician and are listed below:

MYRINGOTOMY WITH TUBE PLACEMENT (INCISION OF EAR DRUM TO ALLOW DRAINAGE OF FLUID AND PLACEMENT OF SMALL PLASTIC TUBE TO KEEP FLUID FROM RECOLLECTING)

Patient Information: Myringotomy with or without tympanostomy tube insertion is the most commonly performed ear operation. It is extremely safe and effective. Potential complications are minor and usually in the form of infection, which may be treated with antibiotics. The tube usually remains in place for 6 to 12 months, although it may be rejected sooner or remain place for years. Post-op care including water precautions are individualized and will be discussed by your physician. Occasionally the tympanic membrane fails to heal after tubes have been removed, and the resulting perforation may require surgical repair. In some cases, tympanostomy tubes may need to be replaced. Hearing improvement is usually immediate after fluid has been removed from the ear. Failure to improve hearing may indicate a second problem in the middle or inner ear.

Known potential adverse effects include:

TUBE COULD FALL OUT PREMATURELY AND REQUIRE
ADDITIONAL PROCEDURES
RECURRENCE OF FLUID COLLECTIONS OR INFECTIONS
REQUIRING REPEAT PROCEDURES AND TREATMENT
NEED FOR FURTHER TREATMENT
INFECTION OF EAR REQUIRING FURTHER TREATMENT ALTERNATIVE THERAPY MAY INCLUDE: OBSERVATION, MEDICAL
TREATMENT

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.

__________________________________________________Date_____________Time_____________ Patient/Legal Guardian

Name(print)_____________________________________Witness______________________________