It is important for you to know you will be required to authorize our surgeons to perform surgery on you. For the sake of clarity in future relationship we have reproduced here the document called "Patient Informed Consent", please read it carefully.
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 .......................
|
5. I have also discussed with the surgeon all the common risks / complications of the operation.
Initial if you understand and agree ....................... |
6. The following have also been carried out:
• I have met the surgeon.
• I have discussed the technique the surgeon will use for my operation.
• I know how long the operation is going to take.
• I know the cost of the operation and mode of payment.
• I know all fees for surgery has to be paid before the surgery and the deposit paid is not refundable after surgery has been carried out.
• I know when I can return to normal activity after operation.
Initial if you understand and agree ....................... |
7. Dizziness may occur during the first week following surgery, particularly upon rising from a lying or sitting position. If this occurs, extreme caution must be exercised while standing. Someone must be present when you shower during the early post-operative period. Do not attempt to walk if dizziness is present.
Initial if you understand and agree .......................
|
8. I understand that secondary revisions or additional surgeries may be required in some cases. The cost of any of these additional surgeries varies from zero to one-half the original surgeon's fee. I understand that I will also be required to pay the additional anesthesia and operating room fees.
Initial if you understand and agree .......................
|
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 .......................
|
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 .......................
|
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 .......................
|
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 ....................... |
I certify that I have read the above consent and I fully understand it. I have been given ample opportunity for discussion and all my questions have been answered to my satisfaction. I have received no medication before signing this consent. I hereby consent to surgery. This constitutes the full disclosure and supersedes any previous verbal or written disclosures.
..............................................................................
