|
 |
1. I voluntarily request plastic surgeon ....................... and the associates, technical assistants, and other health care providers he may deem necessary to assist him in the surgical procedure below mentioned to treat my condition.
The procedure has been explained to me as ....................... |
| Initial if you understand and agree ....................... |
|
|
|
2. I understand that during operation surgeons could discover other or different conditions which require additional or different procedures than those planned. I authorize my physician, and such associates, technical assistant and other health care providers to perform other procedures that are advisable in their professional judgment. |
| Initial if you understand and agree ....................... |
|
|
|
| 3. I understand that no warranty or guarantee has been made to me as to result or cure. Realistic expectations are about 75% improvements. Some patients have great improvement and some have less improvement. |
| Initial if you understand and agree ....................... |
|
|
|
| 4. You must be aware that, although very low in this case, there are some risks and hazards involved in the performance of this surgical procedure which are infection, allergic reactions, bruising, bleeding, hematoma, poor healing, keloid formation. In very rare and extreme cases, death can occur. All possible alternatives for treatment with advantages and disadvantages have been explained to me in detail. |
| Initial if you understand and agree ....................... |
|
|
|
| |
Next |
 |
|
|
|
|
|
|
|
