CONSENT FOR RHINOPLASTY
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 operation known as rhinoplasty, or cosmetic surgery of the
nose. 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. I may not have a nose that is perfectly straight and uncontrollable
swelling may
produce fullness in the tip of my nose.
b. Sensitivity reaction to drugs and anaesthetic materials that are
unknown to me and the doctor is possible.
c. Occasionally, additional surgery is necessary and a charge would
be made for
any additional operative work. Such a possibility is most likely when
one has airway obstruction and other deformities that require surgical
correction for the
appearance of the nose, as well as improvement of the airway.
d. Black eyes, stuffy nose, numbness of the nose, and swelling are
expected for
two to six weeks and may last longer. Some swelling of the nose may
persist
for several months.
e. Any allergy may prevent desired correction of airway obstruction.
f. No guarantee has been given in relation to size, shape or character
of my nose following surgery.
g. If corrective surgery is done on the septum to improve the breathing,
packs will
be placed in the nose which may remain for several days. Bleeding
following
removal of these packs is not uncommon and the packs may need to replaced.
h. The nose may be stiff and tender for an indefinite period of time
and the sense
of smell may be decreased following surgery.
i. Breathing may occasionally be more difficult following this surgery.
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 implants or other 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),
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.
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.
| 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
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