CONSENT FOR COSMETIC TATTOOING

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

INSTRUCTIONS
This is an informed-consent document that has been prepared to help inform you concerning cosmetic tattooing surgery, its risks, and alternative treatment(s). It is important that you read this information carefully and completely. Please sign the consent for surgery as proposed by your plastic surgeon.

ALTERNATIVE TREATMENTS
Alternative forms of non-surgical management consist of using normal, removable make up.

RISKS of Cosmetic Tattooing
Every surgical procedure involves a certain amount of risk, and it is important that you understand the risks involved. An individual’s choice to undergo a surgical procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience these complications, you should discuss each of them with your plastic surgeon to make sure you understand the risks, potential complications, and consequences of the surgical revision of scars.

• Infection- Infection is unusual after surgery. Should an infection occur, additional treatment including antibiotics or additional surgery may be necessary.
• Colour- The dye will be dark initially but will fade with time. The dye may run, leading to an indistinct edge to your tattoo.
• Eyelashes- There is a chance that eyelashes will fall out although they will generally grow back as normal.
• Unsatisfactory result- There is the possibility of an unsatisfactory result from the surgery. You may be disappointed with the results of surgery.
• Allergic reactions- In rare cases, local allergies to tape, suture material, or topical preparations have been reported. Systemic reactions, which are more serious, may result from drugs used during surgery and prescription medicines. Allergic reactions may require additional treatment.
• Surgical anaesthesia- Both local and general anaesthesia involve risk. There is the possibility of complications, injury, and even death from all forms of surgical anaesthesia or sedation.

1. 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 in the hospital. I agree to be responsible for these charges.

2. 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 condition that are not known to or could not reasonably be anticipated by the above doctor(s) at the time the operation is commenced.

3. 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.

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 procedure; nor are there any guarantees against unfavourable results.

5. 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.

6. 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.

7. I understand that the doctors’ fees are separate from the anaesthesia and hospital charges, 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.

8. 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. 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. 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.

9. 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.

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