Authorization for Plastic Surgery Treatment and Procedures

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

Consent for Treatment

I, _________________________, hereby authorize Dr. _________________________ and any designated associates or assistants to perform plastic surgery procedures as discussed and agreed upon during my consultation(s). I understand that this may include, but is not limited to:

• The administration of local or general anesthesia
• Surgical procedures as documented in my surgical plan
• Post-operative care and follow-up treatments

Acknowledgments

1. I understand that no guarantee has been made regarding the final results of the procedure(s).
2. I have been informed of the potential risks and complications associated with the procedure(s).
3. I acknowledge that I have received and reviewed pre-operative instructions.
4. I confirm that I have disclosed my complete medical history.

Financial Agreement

• I understand that I am responsible for all charges not covered by insurance.
• Payment for cosmetic procedures is required in advance of surgery.
• Cancellation fees may apply as per the practice policy.

Photography Consent

• I authorize the taking of clinical photographs for medical documentation.
• I consent to the use of my photographs for teaching purposes (identity concealed).

Emergency Contact

Name: _________________________ Relationship: _____________ Phone: _________________________

Signatures

Patient Signature: _________________ Date: _____________ Witness Signature: _________________ Date: _____________ Physician Signature: _______________ Date: _____________

This authorization is valid for one year from the date of signature unless revoked in writing.