CONSENT TO SURGERY
(NOTE: PLEASE READ THIS FORM CAREFULLY AND COMPLETELY BEFORE SIGNING)
Patient: _______________________________________________
Address: ______________________________________________
I _________________________ hereby authorize DR R. THIND and such assistants as may be selected by the above mentioned, to perform the operation and / or procedure known as:
______________________________________________________.
The nature, potential complications, potential benefits and risk of this procedure as well as the possibility of alternative forms of therapy, have been explained to me by the physician so that I may make an informed decision.
I understand that any medical procedure carries risks. I have understood the risks with this particular procedure
______________________________________________________
I understand that although uncommon and unrelated to negligence, complications may occur.
I understand that it would be impractical and probably misleading to list every possible complication of the procedure mentioned above.
However, I acknowledge that the doctor is available to answer any questions that I might have concerning the above-mentioned procedure. I also acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained. Risks involved such as infection, bleeding, scarring, adhesions, and others may occur.
I hereby grant DR R. THIND permission to photograph / film / videotape me before, during and after the above-mentioned procedure. I understand that the photographs / film / videotape are the property of the photographer.
I consent to the sending of tissue samples removed to an outside laboratory for histological examination if deemed by so DR R. THIND.
I also specifically authorize the above named physician or his assistants, to perform such additional procedures or render such treatment as deemed necessary in his professional judgment in the event that any unforeseen condition arises which would jeopardize my health during the course of, or after, the consented operation.
I certify that I have read and fully understood the above form, that the explanations therein referred to were made and that all blanks or statements requiring insertion or completion were filled in and inapplicable paragraphs, if any were stricken before I signed.
I GIVE MY CONSENT TO HAVE THE ABOVE MENTIONED PROCEDURE(S) PERFORMED UNDER THE ABOVE MENTIONED CONDITIONS.
SIGNATURE OF PATIENT: __________________________________________
SIGNATURE OF WITNESS: _________________________________________
DATE / MONTH / YEAR: ____________________________________________
SIGNATURE OF PHYSICIAN: _________________________________________
REQUEST FOR SURGICAL SERVICES AND INFORMED CONSENT
Patient’s Name: __________________________________________________
Address: ________________________________________________________
To The Patient: You have the right to be informed about your condition and its treatment so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give or withhold your consent for treatment.
I voluntarily request my physician, Dr. Thind and such associates, technical assistants and other health care providers he may deem necessary, to treat my condition. The procedure has been explained to me as _______________________________________________
I understand that my physician can 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 ___________
I understand that no warranty or guarantee has been made to me as to result or cure. Realistic expectations are 50 to 75% improvements. Some patients have great improvement and some have no appreciable improvement.
Initial if you understand and agree ___________
Just as there are risks and hazards of continuing my present condition without treatment, there are also risks and hazards to the performance of the surgical, medical and/or diagnostic procedure is the potential for infection, allergic reactions, bruising, bleeding, hematoma formation or blindness. I also realize that the following risks and hazards may occur in connection with the particular procedure: 1) worsening or unsatisfactory appearance, 2) creation of additional problems such as: a) poor healing or skin loss, b) nerve damage, c) painful or unattractive scarring, keloid formation or permanent skin pigment change or 3) recurrence of the original condition..
Initial if you understand and agree ___________
All possible alternatives for treatment with advantages and disadvantages have been explained to me in detail.
Initial if you understand and agree ___________
I have also discussed with the surgeon all the common risks / complications of the operation.
Initial if you understand and agree ___________
The following have also been carried out.
1) I have met the surgeon.
2) I have discussed the technique the surgeon will use for my operation.
3) I know where the theatre is.
4) I know how long the operation is going to take.
5) I know the cost of the operation and mode of payment.
6) I know all fees for surgery has to be paid before the surgery and the deposit paid is not refundable.
7) I know when I can return to normal activity after operation.
Initial if you understand and agree ___________
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 ___________
I understand that secondary revisions or additional surgeries may be required in some cases. The cost of any of these additional surgeries is 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 ___________
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 ___________
If I am a smoker, I accept the risk of respiratory complications and delayed wound healing resulting from the habit.
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.
NOTE: SINCE SMOKERS HAVE A HIGHER RATE OF RESPIRATORY COMPLICATIONS AND DELAYED WOUND HEALING, SMOKING IS NOT RECOMMENDED BEFORE OR AFTER SURGERY.
Witness Signature: __________________________________________
Patient’s Signature: _________________________________________
Date & Time: ______________________________________________
INFORMED CONSENT FOR LIPOSUCTION
PATIENT: ______________________________________
DATE: _______________________________________
ADDRESS:____________________________________
1. I hereby request the above named surgeon and his associates to perform a surgical operation for excision of fat from my body. The procedure has been completely explained to me by the doctors and I understand its nature and consequences.
________________(initial)
2. I understand that every surgical procedure involves certain risks and possibilities of complications such as bleeding, infection, poor healing, etc., and that these and other complications may follow even when the surgeon uses the utmost care, judgment and skill. These risks have been explained to me and I accept them. The following points have been explained to me in detail.
________________(initial)
(a) Liposuction is a body contouring operation and while every effort is made to smoothly remove the fat. Postoperative irregularities and asymmetries do arise and while such things are often correctable, no guarantee has been made to me with respect to eventual final results of this procedure.
________________(initial)
(b) I understand that small incisions do have to be made and such incisions will result in scars. Such scars could hypertrophy or widen in time and although efforts will be made to conceal them they may be obvious in certain situations and circumstances.
________________(initial)
(c) I understand that although fat is removed from my body, dietary abuse and lack of proper moderation and failure to exercise will result in eventual return.
________________(initial)
(d) Skin changes can occur following liposuction surgery. They involve lumpiness, irregularities, dimples, prolonged swelling and occasional uneven contour. While such things will often resolve in time, permanent changes are possible and depend largely on the patient, his or her age and other physiological factors.
________________(initial)
(e) Swelling is universal in all patients treated and I understand this swelling often persists for two to three months, I agree to be patient and cooperate in every respect, especially in postoperative visits to ensure my proper care.
________________(initial)
(f) I understand the risk involved in liposuction and I am fully aware of the dangers of general anaesthesia. I accept such risks and can fault neither the doctors and/or the anaesthetist if an unfortunate circumstance should arise.
________________(initial)
3. I have an understanding of the operation, which includes, but is not limited to, the above items. I understand that secondary revisions may be required in some cases. The cost of any revisional surgery for additional fat removal is one half the original fee and I understand that I will also be required too pay the anaesthesia fee.
________________(initial)
4. 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 unfavourable results.
________________(initial)
5. I consent to be photographed before; during and after the treatment and that these photographs shall be the property of the above named doctors.
________________(initial)
6. I have read the copy of the foregoing consent for the operation, I understand it, accept these risks and hereby authorise the above doctors to perform this surgical procedure on me.
________________(initial)
7. I authorise the surgeon's fee is ____________. In addition, there will be a separate charge for anaesthesia, which is paid directly to the anaesthesiologist or nurse anaesthetist.
___________(initial)
PATIENTS SIGNATURE: _________________________________ DATE: ________________
WITNESS SIGNATURE: _______________________________________________
LIPOSUCTION - PATIENT INFORMATION AND CONSENT FORM
This procedure was pioneered and developed by Dr. Fournier, a family doctor in Paris , to eradicate ugly localised fatty bulges and thus improved body contour. Localised fat deposits are removed through tubes or cannulas using minimal incisions. Our Doctor uses a special syringe to create negative pressure and the fat is actually sucked from the area to be improved.
The best results are seen when the contour defects are well localised. It is important to stress that this procedure is not a substitute for weight loss or exercise.
The most common areas which can be improved by liposuction are the neck and below the chin; the fatty areas above the breasts adjacent to the arm crease and the fullness that is seen lateral to the breast; breast enlargement in men; the sides of the waist in men (often called love handles); the hips and abdomen in women; the buttocks; the upper inner thighs, the outer thighs in women (saddle - bag deformity); the inner portion of the leg above the knee and less often the calves, ankles or arms. Contour defects both after surgery or injury can be improved by this suction technique.
Liposuction, until recently, was performed in a hospital under general anaesthesia. Now, with new techniques, both in the field of local anaesthesia, use of tiny suction tubes and in defining and limiting the areas that are to be treated at one time, it is performed as on outpatient procedure.. This prevents a hospital stay of 2 to 4 days especially when multiple or extensive areas are treated and eliminates the sometimes need of blood transfusion. Consequently, our procedure is much safer and much less painful.
We recommend a commercially made support garment or a snug dressing for at least seven to fourteen days after treatment. Later, some form of support dressing is used for between three and six weeks. Regular bathing or shower activities can be resumed in a few days. Always check with your Doctor regarding a light massage programme in the post-operative period.
Normal daily activities can be resumed the next day; reasonable activities at the end of the first week, with more strenuous activities resuming in approximately three to four weeks.
Initially swelling occurs where the treatment has been carried out especially when the knees or inner thighs are treated ankle swelling occurs and this can last several weeks. When the lower legs are treated a stocking is needed for 6 weeks, as the swelling is more recalcitrant.
The collection of blood in the area of the operation (a haematoma) or watery fluid (seroma) may arise infrequently.
There has been reported in the literature an area of skin loss (sloughing). Fortunately, this is even more infrequent when limited liposuction under local anaesthesia is carried out. A very rare complication is a deep venous thrombosis. This is even more rare when the liposuction is performed under local anaesthesia and indeed with our techniques where in your continuation in daily activities, this is extremely rare. This is serious if pulmonary emboli develop (clots in the veins, which travel to the lungs).
The benefits of the procedure may not be totally appreciated before eight weeks. One must not be disappointed in the first few weeks after treatment. The final result can be seen in approximately six months.
The above information mentions most but not all of the problems and benefits that are derived from the procedure; should there still be any questions, please ask the Doctor for an answer before undertaking treatment. The patient who is well informed about the risks and benefits is then realistic in their expectations and remain very supportive and happy with the results. Reliable information rarely comes from well meaning friends.
The Doctor cannot guarantee the results with any operation. The realistic aim of this operation is improvement not perfection.
Photos are taken for the medical record and to document your progress. They remain the property of the L'Image Cosmetic Surgery and may be used for medical or educational purpose.
I agree to follow the instructions given to me by my Doctor, to the best of my ability before, during, and after my procedure and notify him of any problems that occur.
I hereby acknowledge that I have read this information on liposuction, and have discussed this and asked questions of my Doctor, who has answered them to my understanding, and satisfaction.
