Informed Consent:

I,............................................................... have had the procedure of radio-frequency surgery for snoring explained to me, and I understand the risks, the post-operative course, and likely outcome of this operation. I accept that repeated surgery might be required. I also understand that there is a small possibility that this procedure may not relieve my snoring. I have had the opportunity to ask any questions, and address any concerns.

The surgery to be performed includes:

• Radiofrequency Tissue Volume Reduction of the soft palate
• Radiofrequency Tissue Volume Reduction of the turbinates (In the nose, only if required.
• Other applications of the Surgitron technology

I therefore consent to the surgery as explained to me.

Signed:................................................... Date:.......................