BROWLIFT CONSENT

DARRYL J. HODGKINSON M.D. F.R.C.S.(C) F.A.C.S.

1. I hereby authorise the above-named surgeon(s) to perform a surgical operation known as browlift.
2. The procedure has been explained to me by the above doctor, and I understand the nature and consequences including possible risks of the procedure.
3. The following risks and side effects have been specifically made clear to me:

   a. That there are always scars following this procedure. Every effort will be made to make them as inconspicuous as possible.
   b. That there may be swelling in the face which can persist for several weeks and, in rare cases, longer following the procedure.
   c. There may be discolouration of the skin (black and blue) for several weeks.
   d. There may be scattered areas of numbness over the face and neck following surgery which may persist for an indefinite period of time.
   e. That no guarantee has been made as to the amount of improvement either in terms of apparent age or the permanency of the result.
   f. That at times fluid or blood may accumulate in the operative sites which may require aspiration or drainage.
   g. Surgery necessary to perform the procedure, as in all surgery, involves certain risks, including but not limited to the following:

   1. Bleeding
   2. Infection
   3. Tissue Damage
   4. Nerve Injury
   5. In rare cases, death or other serious bodily injury.
4. I recognise that during the course of the operation, unforeseen conditions may necessitate additional or different procedures than those set forth above. Also, emergency conditions may require performance of additional medical procedures. I therefore further authorise and request that the above-named doctor(s) perform such procedures as are, in his or her professional judgment, necessary and desirable, including but not limited to, procedures involving pathology and radiology. The authority granted under this Paragraph 4 shall extend to remedying conditions that are not known to the above doctor at the time the operation is commenced.
5. I consent to the administration of anaesthetic to be applied by or under the direction and supervision of the above doctor, anaesthetist, that he selects and to the use of such anaesthetics as he may deem advisable.
6. Because of any special conditions you may have such as high blood pressure, etc, your risk of undesirable side effects are greater than normal and you should consider that factor of added risk in your decision of whether or not to proceed with the surgery.
7. I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees or representations have been made as to the ultimate result of the operation or procedure.
8. I consent to be photographed before, during and after the treatment; that these photographs shall be the property of the above doctor and may be published in scientific journals and/or shown for scientific reasons.
9. I agree to keep the above doctor informed of any change of address so that he can notify me of any late findings, and I agree to cooperate with the above doctor in my care after surgery until completely discharged.
10. I understand that the doctors’ fees are separate from the anaesthesia and hospital charges, and the doctor’s fees are agreeable to me. There may be a fee if a secondary procedure is required. Personal expectations vary; please ensure that you have liaised with your doctor and he has understood your expectations of surgery. Some operations require secondary or multiple procedures to obtain a better result.
11. Secondary surgical procedures are much more difficult than primary procedures. The operations for repair are much more complex than the primary operations because of scarring and more bleeding and bruising. The possibility of nerve damage and poor healing is greater and most importantly, the results are unpredictable. It is important for the patient to realise that the results of secondary surgery will never be as predictable as those of primary surgery. If a secondary procedure is necessary, further expenditure will be required, namely surgeon’s fees, the use of the operating room, anaesthesia and possibly hospitalisation. Before embarking on secondary surgery, you should be aware of your possible future commitments to multiple procedures in order to gain an acceptable result for yourself.
12. I have read the above consent and fully understand the same and do authorise the above doctor to perform this surgical procedure on me.
    

IF THE PATIENT IS A MINOR, COMPLETE THE FOLLOWING

The patient is a minor of ______ years of age; and we, the undersigned, are the parents or legal guardian of the patient and do hereby consent for the patient.

Parent or Legal Guardian ______________________________________________________________

Witness____________________________________________________________________________

20 Manning Road Double Bay N.S.W. 2028 Telephone: (02) 9362 7400 Facsimile: (02) 9328 6036