CONSENT FOR PECTORALIS IMPLANT

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

1. I, ........................................................................ consent to the performance of a pectoralis, implant to be inserted surgically into my body by Dr Darryl Hodgkinson and whosoever he names to assist him in this procedure.
2. I understand that surgery of any kind encompasses risks from anaesthesia including in very rare cases, cardiovascular or respiratory complications which could be fatal. I understand that the general risks of surgery include haemorrhage, infection, bruising and swelling. Scars will be
   present and may thicken or stretch.
3. Specifically as regards the body implant, it is made of solid silicone and the consequences of this implant are not fully known at this time. No implant can last forever and a possibility of breakage or slippage exists. The immunological consequences of silicone implants are under investigation at this time and the consequences are not known at this time. Perfect symmetry is not likely to be achieved with the implant. Changes in body shape may make the implant palpable or visible under the skin.
4. I agree to be photographed before and after the procedure. The purpose of these photographs is for scientific and medical study. At the doctor’s discretion I agree to these photographs being published in medical articles.
5. During a surgical procedure, difficulties may arise which require action not previously discussed. I agree to have Dr Hodgkinson deal with these difficulties as he sees fit. I understand that secondary procedures are occasionally needed to obtain the final result. I accept that if referral to a hospital or other specialist is required that the expenses of both the hospitals, the specialists or medications would have to be met by myself.
6. 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.
7. 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.

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____________________________________________________________________________

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