Bechara Y. Ghorayeb, MD, PA
Otolaryngology-Head & Neck Surgery                                                              Phone: 713 464 2614
1140 Business Center Drive, Suite 560
Houston, TX 77043                   www.ghorayeb.com


Septoplasty / Submucous Resection of Septum (SMR)
Informed Consent
Septoplasty is an operation to correct a deformity of the partition between the two sides of the nose. The usual purpose is to improve breathing, but it may also be required to permit adequate examination of the inside of the nose for treatment of polyps, inflammation, tumors, or bleeding. When the nasal septum is deformed, there is no medicine that will cause it to be straightened, so surgery is the only solution to this problem. The undesirable results that may occur include a hole in the septum, failure to completely improve breathing, postoperative bleeding (usually easy to control), nasal crusting, and very rarely, a change in appearance. Because of the proximity of the dissection to the incisors, these teeth and a small area of the hard palate behind them, may feel numb for 2 to 3 months.


I/We have been given an opportunity to ask questions about my condition, alternative forms of treatment, risks of nontreatment, the procedures to be used, and the risks and hazards involved, 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.


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Patient / Legal Guardian
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Witness

Date:___________________________          Time:___________________________


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