CONSENT TO REPAIR A FACIAL DEFECT (POST MOHS SURGERY)

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 the surgical operation of repair of a facial defect. 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. From every defect of the skin in whatever part of the human body, there will be a scar.
b. The eventual appearance of the scar will be variable and dependent on the healing of the scar.
c. The scar will require a healing period of up to one year before any further revision surgery would be undertaken to improve the appearance of the scar.
d. Stitches or sutures will be used to sew the cut skin and deepest structure together. Occasionally, a stitch will work to the surface and have to be removed.
e. Firmness in the area and redness of the scar are to be expected for an indefinite period of time after repair of the defect. Swelling and bruising will probably last for up to two or three weeks after repair of the defect. I also understand that there may be some displacement of the tissues which may or may not be permanent, depending upon the degree of difficulty of the defect.
f. If flaps of skin are used, there may be swelling which may require revisionary medical or surgical services. Fees will be incurred for further revisionary surgery.

3. I understand that the above-named surgeon and his associates are plastic surgeons and their fees reflect the high degree of skill, surgical judgment and training that they have. I understand that the responsibility for payment of their fee is mine and not the responsibility of my insurance company. I agree to be responsible for all charges made in the repair of the facial defect and also responsible for any future revisionary surgery which might be required to improve the appearance of the scars.

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 emergency room charges and that they are my responsibility completely. 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 the surgical procedure of repair of a facial defect 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