<<
Back to Previous Page
General Consent Form |
Face/Neck/S Lift
When undergoing one of our procedures it is a
requirement that a consent form is signed both
before the surgery and on the day of the surgery.
The reason for this process is to ensure that
you are fully informed in regards to the procedure
and possible complications that may arise as a
result of the procedure.
General
Consent Form
Below we have provided the text of our standard
consent form. Other forms may be used in the case
of some of our procedures. For further details
please contact us.
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 in the
case of eye surgery blindness. I also realize
that the following risks and hazards may occur
in connection with the particular procedure:
- Worsening or unsatisfactory appearance,
- Creation of additional problems such as:
- poor healing or skin loss,
- nerve damage,
- painful or unattractive scarring, keloid formation
or permanent skin pigment change or
- 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:
- I have met the surgeon.
- I have discussed the technique the surgeon
will use for my operation.
- I know where the theatre is.
- 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.
- 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.
Signatures from the patient and a witness will
be required before surgery and on the day of the
surgery.
Consent
form for Face Lift / Neck Lift / S Lift
Below we have provided the text of our facial
consent form. Other forms may be used in the case
of some of our procedures. For further details
please contact us.
1. I hereby request Dr. R. Thind to perform “face
lift”/ “neck lift” surgery on:......
2. The procedure listed in Paragraph 1 has been
explained to me by the doctor and/or his staff
and I completely understand the nature and consequences
of the surgery. The following points have been
specifically made clear:
A. That medicine is not an exact science and
complications such as death, although extremely
rare, may occur.
B. That swelling, bruising and mild discomfort
usually occur.
C. That no guarantees with respect to the final
outcome and its longevity can be offered.
D. That infection is possible.
E. That sensation may be altered or completely
lost.
F. That function may be altered and that rarely
injuries to the facial motor nerves can occur,
resulting in weakness of facial muscles.
G. That delayed wound healing and/or poor scarring
may occur.
H. That revisions may be necessary.
I. That the healing process takes time and the
final result will not be readily visible for many
weeks and possibly months.
J. That bleeding may occur and should blood collect
(a hematoma), this may require further surgical
treatment.
K. That skin loss may occur and that smoking may
cause this problem.
L. That chronic or persistent problems may occur
which require treatment.
M. That asymmetry (one side of the face does not
match the other side) is possible.
N. That small areas of temporary or permanent
hair loss may occur.
3. I understand that a “S” Lift is
essentially a mid face lift and not a neck lift.
As such the improvement of the neck is limited.
4. 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 authorize
and request that the above-named surgeon, his
assistants or his designees perform such procedures
as are, in his professional judgment, necessary
and desirable, including, but not limited to,
procedures involving pathology and radiology.
The authority granted under this Paragraph 3 shall
extend to remedying conditions that are not known
to the above doctors at the time the operation
is commenced.
5. I understand that transverse forehead lines,
deeps glabellar creases and transverse lines at
the root of nose can be improved by brow lifting
but these lines cannot be eliminated.
6. Similarly crow’s feet lines can be improved
to some degree but never eliminated.
7. Malar pouches below the eyelid bags do not
disappear after face lifting and occasionally
are accentuated during the immediate post operative
period.
8. Nasolabial folds can be softened but they can
never be eliminated.
9. “Marionette lines” from the corner
of the mouth to the border of the jaw never disappear
completely.
10. A short neck precludes an ideal cervicomental
angle. (i.e.) neck lift.
11. “Ptotic” or hanging salivary glands
are at angle of your jaws are difficult to deal
with.
12. Skin has numerous fine wrinkles and they may
need a chemical peel or laser.
13. Smoking increases the risk of skin slough.
“Rees and Colleagues” have reported
a risk of skin slough 12 times greater than non-smokers.
Patients are requested to stop smoking for two
weeks. However the risk in smokers remain.
14. I consent to the administration of anesthesia,
and/or deep sedation, to be applied by or under
the direction and supervision of Dr. R. Thind
or such anesthesiologists as he selects and to
use such anesthetics as may be deemed advisable,
with the exception of ................(None or
a particular one)
15. 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 procedure.
16. I consent to be photographed before, during
and after treatment, that these photographs shall
be the property of Dr. R. Thind and may be published
in scientific journals and/or shown for scientific
or educational reasons.
17. I agree to keep Dr. R. Thind informed of any
change of address so that he can notify me of
any late findings, and I agree to co-operate with
the doctor and his staff in my care after surgery
until completely discharged.
18. I have read the above consent and fully understand
the same and do authorize Dr. R. Thind to perform
this surgical procedure on me.
19. I am not known to be allergic to anything
except: (list) ...........
20. I do not desire to have further explanation,
discussion or description of the operation, anesthesia
or risks involved.
Signed by witness and patient...............
IF THE PATIENT IS A MINOR, COMPLETE THE FOLLOWING:
Patient is a minor ...........years of age, and
I (we), the undersigned, am (are) the parent(s)
or guardian of the patient and do hereby consent
for the patient.
Signed by witness and patient...............
IF THE PATIENT IS FOREIGN OR A NON-RESIDENT, COMPLETE
THE FOLLOWING:
I agree that the relationship between myself and
Dr. R. Thind shall be governed by the, and construed
in accordance with the laws of New South Wales.
Also, I acknowledge that the treatment/service
was performed in New South Wales and that the
courts of New South Wales shall have jurisdiction
to entertain any complaint, demand, claim or cause
of action, whether based on alleged breach of
contract or alleged negligence arising out of
treatment. The patient hereby agrees that he/she
will commence any such legal proceedings in New
South Wales and only in New South Wales and hereby
submits to the jurisdiction of the Courts of New
South Wales.
Signed by witness and patient...............
<<
Back to Previous Page
|
