CONSENT FOR INSERTION OF CHIN IMPLANTS
DARRYL J. HODGKINSON M.D. F.R.C.S.(C) F.A.C.S.
1. I hereby request the above named surgeon(s) and/or their associates
to perform a
surgical procedure known as insertion of chin implants. This procedure
has
been explained to me and I completely understand its nature and consequences.
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 in detail:
a. There will be a scar inside my mouth or under my chin for a chin
implant, and
the malar (cheek) implant.
b. Bleeding or infection around the implant may require removal
of the implant.
c. Although every attempt will be made to make both cheeks the same
following
surgery, the appearance of the cheeks may not be identical in size,
shape, or
height.
d. Cheek implants may slip, and the edges of the implant may sometimes
palpable
or visible.
e. Numbness of parts of the cheek or chin is common following surgery
but
usually is temporary. Rarely, it may be permanent.
f. The implant material does not, to our knowledge, increase or
decrease the
chances of cancer developing.
g. This type of operation has been done for several years, but the
end results are
not and cannot be determined for a number of years yet to come.
h. As a result of scarring around the implant, the cheeks/chin may
feel hard to the
touch.
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. I also
understand that charges will be made for the use of the operating room,
whether in
the day surgery or the hospital and for any additional implants or materials
required. I
agree to be responsible for these charges.
4. I recognise that, during the course of the operation, unforeseen
conditions may
necessitate additional or different procedures than those outlined.
I, therefore, further
authorise and request that the above-named surgeon or his/her assistants
perform
such procedures as are, in his or her professional judgment, necessary
and desirable.
The authority granted under this Paragraph 4 shall extend to remedying
conditions that
are not known to or could not reasonably be anticipated by the above
doctor(s) at the
time the operation is commenced.
5. I consent to the administration of local or general anaesthetic
agents by or under the
direction and supervision of the above doctor(s), anaesthetist, or nurse
working with
them.
6. 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; nor are there any guarantees against an unfavourable
result.
7. I consent to be photographed before, during and after the surgery;
that these
photographs shall be the property of the above doctors and may be used
as they deem
proper for scientific and educational purposes.
8. I agree to keep the above doctor(s) informed of any change of address,
and I agree to
cooperate with them in my care after surgery until completely discharged.
9. I understand that the doctors’ fees are separate from the
anaesthesia and hospital
charges, and implant costs and the doctors’ 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.
10. 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.
11. I have read a copy of the foregoing consent for the operation,
understand it, accept these facts, and hereby authorise the above doctor(s)
to perform this surgical
procedure on me.
| Patient’s Name (Please Print) |
_____________________________________________ |
| Patient’s Signature |
_____________________________________________ |
| Date |
_____________________________________________ |
| Witness |
_____________________________________________ |
| Date |
_____________________________________________ |
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
|
