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9. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me as to the results of the operation or procedures nor are there any guarantees against an unfavorable result. I acknowledge that you will do your best for me but I also recognize that you lack infallibility and that mistakes and accidents can occur in medicine as they can in any discipline. In the absence of a deliberate, premeditated act of negligence, I will not sue you. |
| Initial if you understand and agree ....................... |
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10. I agree to be photographed before and after the procedure. The purpose of these photographs is for scientific and medical study. At the doctor's discretion I agree to these photographs being published in medical articles. If published in doctors' websites, photos will be retouched in order to remove from them any distinctive mark that could identify me as tattoos, birth marks, etc. and also my face will be hidden or made unrecognizable unless I agree to appear just as I am. |
| Initial if you understand and agree ....................... |
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11. If I am a smoker, I accept the risk of respiratory complications and delayed wound healing resulting from the habit. I am informed that surgery is not recommended for heavy smokers. |
| Initial if you understand and agree ....................... |
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12. I have received a thorough explanation of my preoperative and postoperative instructions. I understand these instructions and have received copies for reference. I understand that should I have any questions about the preoperative or postoperative instructions I should not hesitate to call. I acknowledge my obligation to follow these instructions closely and to visit the clinic for follow up care and instructions on postoperative day one, five and ten. |
| Initial if you understand and agree ....................... |
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