CONSENT FOR DERMABRASION

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

1. I hereby request the above named surgeon and/or his associates to perform a surgical procedure known as Dermabrasion, commonly referred to as sanding or skin planing. This procedure has been explained to me by the doctor(s) 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. That while a certain amount of improvement is anticipated, the exact amount of change in the appearance of the skin cannot be accurately predicted. Secondary procedures may be necessary to achieve your desired result. This is more often seen with acne scars. Improvement will always be achieved.

b. That during the Dermabrasion process, there is discomfort and swelling following surgery. A dressing will be applied following the procedure.

c. That the skin will have a reddish appearance which may persist for several weeks; that at the juncture of the treated and untreated areas, there is a difference in colour, pigmentation, and texture of skin and the treated skin is dry and scaly.

d. That in some cases, alterations of pigmentation may occur in the treated areas.

e. Many small white pinhead sized spots from plugged pores may occur for an indefinite period of time following surgery and can be treated as they arise.

f. Although infection following laser skin treatment is unusual, bacterial, fungal and viral infections can occur. Herpes simplex virus infections around the mouth, can occur following a laser treatment. This applies to both individuals with a past history of Herpes simplex virus infections and individuals with no known history of Herpes simplex virus infections in the mouth area. Specific medications can be prescribed and taken both prior to and following the laser treatment procedure in order to suppress an infection from this virus. Should any type of skin infection occur, additional treatment including antibiotics may be necessary.

g. The skin so treated will be more sensitive to heat, hot water and sunlight for several weeks. Excessive sunlight should be avoided for three months or more.

h. Sanding may cause a thickening of the skin from formation of scar tissue, especially if any areas become infected.

i. Small fine broken capillaries may arise in certain individuals, usually in those with very fine skin. This can be treated with another type of laser, which is a very small procedure.

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 in the hospital, and for any additional 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) or anaesthetist, 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 unfavourable results.

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.

The Importance of Follow-up.

Patient follow through following a laser skin treatment procedure is important. Post- operative instructions concerning appropriate restriction of activity, use of dressings and use of sun protection need to be followed in order to avoid potential complications, increased pain and unsatisfactory result. Your physician may recommend that you utilise a long-term skin care program to enhance healing following a C02 laser skin treatment.

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.

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