There are times when your doctor may need to perform an in-office procedure called Diagnostic Endoscopy. Diagnostic Endoscopy provides clinical information when there may be a condition or disease in the nose or throat that is not adequately visualized on routine exam. The procedure is done using a fiberoptic or rigid endoscope. After nasal spray is used to shrink and numb the nasal membranes, the instrument is usually passed through the nose so structures in the nose, mouth, and throat can be directly observed. Complications associated with this exam are rare but may include sneezing, coughing, gagging, bleeding, and/or minor discomfort.

When this procedure is medically advised:

I hereby authorize my doctor or his/her associates to perform diagnostic endoscopy. I understand and acknowledge the benefits and risks of the procedure(s) as explained above.   

I decline to have diagnostic endoscopy. I am aware that this procedure is recommended based upon my symptoms, physical exam and/or history. I understand that declining this procedure my lead to an incorrect or lack of diagnosis which may adversely impact my treatment and outcome. I understand the risks associated with refusing this procedure.   

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Insurance companies may consider diagnostic endoscopy an in-office surgical procedure and may assign additional financial responsibility to the patient when processing a claim. I understand that by signing this consent form I am also committing to satisfying the financial responsibility for this procedure as established through my policy coverage.

If you have any questions please do not hesitate to ask our staff or your Doctor for more information.

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