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 PECTORAL IMPLANT

Patient: ___________________________________________

Date: ____________________________________________

Address: __________________________________________

1. I hereby request & authorized Dr. R. Thind and assistants of his choosing to perform a surgical procedure known as PECTORAL ENHANCEMENT on:

Name of patient of (myself): __________________________________

2. The procedure listed in paragraph one (1) has been explained to me by Dr. Thind including the goals limitations and possible complications of this operation. The following points have been specifically made clear:

a) The incision required for the placement of the breast implant will heal by forming a scar. Every effort will be made to make the scar as inconspicuous as possible. I have discussed the three possible areas of incision placement with Dr. Thind and have chosen

_________________________________________________________

b) Bleeding around the breast implant following a closure of the incisions is a possible complication of breast augmentation and could possibly require re-operation for control. Should re-operation be required, I understand that Dr. Thind will not charge a surgical fee, but if general anaesthesia is selected, I will be responsible for the anaesthetist’s fee. In order to minimize the risk of bleeding, I agree to avoid taking aspirin or aspirin containing products for at least two (2) weeks before surgery and to maintain control of my blood pressure medications previously prescribed before and after surgery.

c) Although antibiotics will be prescribed at, and after surgery, I understand the infection in the incision or around the breast implant is a possibility. if infection occurs and does respond to antibiotic treatment, it may be necessary to remove the implant and replace it after the infection has subsided. No surgical fee will be charged should implant removal be necessary, but a small fee (in addition to the anaesthetist’s fee) will be charged for implant replacement. I understand that I will also be responsible for the cost of a new implant.

d) Dr. Thind has explained that firmness around the implant may develop in an effort to reduce the incidence of this problem, I have chosen a saline implant with a textured surface. Although the use of these textured implants has been associated with greatly reduced incidence of breast firmness, I realize that because of the nature of the human body, each person may react differently to a breast implant, and thus no ethical surgeon can guarantee that my breast will be as soft as I desire. If breast firmness develops post-operatively, I understand that it can be treated subsequent operation, but no guarantee can be given as to the result of the second operation I also understand that the manufacturer of the implant give no guarantee as to how long they will last before needing a replacement.

e) I have thoroughly discussed implant size and have observed the effect of various implant sizes when placed in my bra. Dr. Thind has explained that when placed surgically, an implant is generally slightly smaller than the same implant appears when placed on top of the breast in a bra. After a careful consideration, the implant size that I have chosen is _________________. I understand that if for any reason I am unhappy with the implant size following surgery, an implant of different size can be placed subsequently. If this is desired, I understand that a surgical fee in addition to an anaesthesia fee will be charged. I understand that I must also pay for the new implants.

f) Numbness or tenderness of the nipples or skin around the incision may be present after surgery but this generally temporary. A change in sensation of the nipples that may be permanent is uncommon; this is a most unlikely occurrence.

g) Occasionally, breasts become firm following implant surgery. The implant itself does not become firm, but the firmness is due to the formation of capsule of scar tissue around the implant. If this capsule contracts excessively it will squeeze the implant into firmness. While some firmness is beneficial, it should be noted that with the newer type of textured implants, a very small number of patients develop some firmness to a mild degree.

h) I understand that no ethical surgeon can make guarantees as to the result of this or any cosmetic surgical operation. I understand that the surgical fee is paid for the performance of the operation itself and does not constitute a guarantee of the surgical result.

3. I recognize that, during the course of the operation, unforeseen conditions may necessitate additional or different procedures than those set forth above. I therefore further authorized and request that Dr. Thind, his assistant or his designees perform such procedure as are, in his professional judgment, necessary. The authority granted under this paragraph includes remedying condition that is not known to the above doctor(s) at the time the operation is commenced.

4. I request and authorize the admission of the anaesthesia to applied by or under the direction and supervision of Dr. Thind or an anaesthetist that he may select and to the use of such anaesthetics as they may deem advisable, with the exception of (none or particular one):

____________________________________________________________

5. I am aware that the practice of medicine and surgery is not an exact science, and acknowledge that no guarantees have been made to me as to the result of the operation or procedure.

6. I consent to be photographed before, during and after the treatment, that these photographs shall be the property of the above doctor(s) and maybe published in scientific journals and / or shown for scientific reasons.

7. While I realize that Dr. Thind will do his best to achieve the optimum surgical result, I understand that both the surgeon and myself have responsibilities in achieving this result. I therefore agree to follow all instructions, both before and after surgery. I understand that improvement, not perfection, is the goal of cosmetic surgery.

8. I understand that if Dr. Thind feels that it is advisable to refer me to an another Physician or Physicians for evaluation of treatment, I will be responsible for any fees or related cost.

9. I am not known to be allergic to anything except (list):

___________________________________________________________

___________________________________________________________

I HEREBY releases and forever discharge Dr. R. Thind from all actions, claims, suits and demands whatsoever that I may now have or may hereafter have had against Dr. R. Thind arising from or in any way connected with the treatment.

The Deed may be pleaded by Dr. R. Thind in bar to any action, claim, suit or demand brought by me or any person claiming through him/her for damages arising out of the treatment.

Discussed surgical procedure material risks and complications, viable alternatives and their material risks and complication and all questions answered.

My signature certifies that:

a) I have discussed the above information with Dr. Thind.

b) I have been given the opportunity to ask questions about this operation including it’s goals, limitation and possible complications and all questions have been answered to my satisfaction.

c) I received this request for surgical services at least seven days prior to operation. I have read it and understand it completely and in light of the above, I hereby and agree to hold Dr. Thind and his medical staff and assistants from any claim of any nature arising by virtue of the procedure set out above.

d) I do request and authorize Dr. Thind to perform this operation on me.

IMPORTANT: DO NOT SIGN THIS DOCUMENT UNLESS YOU HAVE FIRST READ IT AND UNDERSTAND IT.

Patient:_____________________________________________________________

Witness: ___________________________________________________________

Physician: _________________________________________________________