CONSENT FOR OTOPLASTY
(Repositioning or reshaping of the ears)

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 otoplasty. 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 swelling and discolouration in and about the ears for several days.
b. That every attempt will be made to achieve symmetry but the ears may not
have exactly the same size, shape, curvature, or projection from the head.
Secondary surgical adjustment of position may be required.
c. There will be permanent scars on the back of the ear and the ears will be
somewhat numb and uncomfortable for an indefinite period of time. The scars
may thicken and require additional treatment or surgical revision.
d. Physical injury after the otoplasty procedure would disrupt the results of
surgery. Care must be given to protect the ear(s) from injury during the healing
process. Additional surgery may be necessary to correct damage.
e. Wound disruption or delayed wound healing is possible. Some areas of the ear
may heal abnormally or slowly. Frequent dressing changes or further surgery to
remove the non-healed tissue may be required.

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 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) and 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 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.

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