Informed Consent Form For Plastic Surgery

1. Dr Sanjay Saraf
INFORMED CONSENT FORM FOR
PLASTIC SURGERY

2.  I hereby authorize Plastic Surgeon and his
associates to perform Plastic Surgical
procedure on me. I fully understand that this
procedure has limited application. I am
aware that the practice of medicine is not an
exact science, and I acknowledge that no
guarantees or assurances have been made
to me as to the results/success of the
operation or procedure. Doctor has
discussed in detail with me the information
that is briefly summarized below.

3.  A. NATURE AND PURPOSE
Plastic, reconstructive and cosmetic surgery refers to a variety
of operations or procedures performed in order to repair or
restore body parts to look normal, or to change a body part to
look better.
 B. RISKS
Every surgical procedure involves a certain amount of risk, and
it is important that you understand the risks involved. The risks
associated with plastic, reconstructive and cosmetic surgery
include the intra-operative/post-operative complications that can
occur with any surgical operation under anaesthesia. Although
the majority of patients do not experience the following
complications, you should be aware of the risks, potential
complications, and consequences of surgery. The general risks
like clots in the legs with pain and swelling (rarely part of this
clot may break off and go to the lungs which can be fatal),
allergy/reaction to medicines, heart attack, stroke and rarely
death.

4.  In addition, plastic, reconstructive and cosmetic surgery also
carry specific risks like:
 (a) Formation of undesirable scar
 (b) Formation of haematoma
 (c) Infection
 (d) Persistent pain, redness, or swelling in the area of the
surgery
 (e) Failure of implants/prosthesis
 (f) Fat embolisms from liposuction
 (g) Rejection of skin grafts/failure of flaps or replants
 (h) Loss of normal sensation/power/function in the area of the
operation
 (i) Pigmentary changes/contour abnormalities
 (j) Procedure specific complications
 (k) Complications resulting from unforeseen problems

5.  C. ANAESTHESIA
I understand that local/regional or general anesthesia
is required for surgery. Suitability of anaesthesia will
be assessed by the surgeon/anaesthetists. There is
the possibility of complications, injury, and even
death from all forms of anaesthesia.
 D. FINANCIAL RESPONSIBILITIES
The cost of surgery includes charges for the surgery,
theatre charges and the anaesthesia charges as per
the total duration of surgery. The charges for
laboratory tests, hospital stay, consumables and
medicines are separate. Follow up visits and any
secondary surgery charges are not included in this.

6.  E. PHOTOGRAPHS
I consent to be photographed before, during
and after the treatment, these photographs
shall be the property of the hospital/doctor
and they may be published in scientific
journals and/or shown for scientific reasons.

7.  F. INFORMED CONSENT
I have had sufficient opportunity to discuss my condition and
proposed surgery with the doctor and all of my questions have
been answered to my satisfaction regarding:
1) The nature/type of proposed procedure/surgery
2) The alternative options
3) The need for multiple procedures/surgeries
4) Risks/complications of this surgery
5) The possibility of never regaining all previous
functions/appearance
6) All possible other complications, sequelae and possible
resulting deformity.
7) Scars of the surgery will be visible and additional scars may
occur as part of the treatment.

8.  8) In case of replantation/revascularisation/complex surgeries
of finger or hand the possibility of blackening of the finger/hand
with possibility of immediate/delayed amputation.
 9) I will be responsible for the outcome of the surgery if I do not
follow post-operative instructions or fail to follow up regularly.
 10) The choice to undergo the above procedure and/or
treatment is mine alone
 11) I have had the opportunity of asking questions that I can ask
more questions
 12) I give consent for surgery by any additional doctor
considered necessary
 13) I authorize my surgeon to perform any other procedure that
may deem desirable in attempting to improve the condition or
any other unforeseen condition that may be encountered during
the operation
 14) I have been explained regarding the insurance status.
 15) I give consent for necessary investigation

9.  I believe I have adequate knowledge on which to
base an informed consent to the proposed treatment.
I have been explained regarding the procedure,
prognosis and expenses. I am signing this informed
consent form by my free will, without any coercion,
obligation and after understanding all aspects of it.
 Signature of the witness Date:
 Signature of the patient/Guardian Date:

10.  I believe I have adequate knowledge on which to
base an informed consent to the proposed treatment.
I have been explained regarding the procedure,
prognosis and expenses. I am signing this informed
consent form by my free will, without any coercion,
obligation and after understanding all aspects of it.
 Signature of the witness Date:
 Signature of the patient/Guardian Date: