CONSENT TO REPAIR FACIAL TRAUMA
(Lacerations and Fracture)
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 facial injury and/or facial fracture.
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 laceration of the skin and every incision in the face
or mouth, 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.
d. When facial bones are fractured, underlying nerves may be damaged
and are of
the face may remain numb or painful for an indefinite period of time.
e. The appearance of the face may possibly be altered if the bones
do not heal
ideally.
f. If the jaws are fractured, the occlusion of the teeth will be
altered; and a dental
or oral surgeon may need to perform procedures to improve the occlusion
after
the bones have healed.
g. If the bones around an eye are broken, the eye may become sunken.
Every
effort will be made to prevent this from occurring.
h. All facial injuries are accompanied by bruising and swelling,
which may take
weeks or months to resolve completely.
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 laceration/facial fracture and also responsible
for any future
revisionary surgery which might be required to improve the appearance
of the
scar/facial bones.
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 facial trauma 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
|
