Comprehensive Plastic Surgery Informed Consent Form

PATIENT INFORMATION

Name: _________________________ Date of Birth: _____________ Procedure(s): ____________________________________________ Date of Surgery: _________________________________________

1. PROCEDURE DETAILS

I, _________________________, hereby authorize Dr. _________________ and assistants to perform the following procedure(s):

• Primary procedure: _______________________________________
• Additional procedures: ___________________________________

2. RISKS AND COMPLICATIONS

I understand that this procedure carries risks including but not limited to:

• Bleeding and hematoma formation
• Infection
• Adverse reaction to anesthesia
• Unsatisfactory scarring
• Asymmetry
• Changes in sensation
• Need for revision surgery
• Deep vein thrombosis
• Seroma formation

3. ALTERNATIVE TREATMENTS

I acknowledge that alternative treatments include:

• Non-surgical options: _____________________________________
• Alternative surgical approaches: ____________________________
• No treatment

4. PHOTOGRAPHY CONSENT

□ I consent to photography for medical documentation □ I authorize use of photos for teaching/publication (optional)

5. FINANCIAL RESPONSIBILITIES

I understand that:

• This procedure may not be covered by insurance
• I am responsible for all costs not covered by insurance
• Additional costs may arise from complications or revision procedures

6. PATIENT ACKNOWLEDGMENT

I confirm that:

• All my questions have been answered satisfactorily
• I have read and understand all information presented
• I am not under the influence of drugs or alcohol
• I accept the risks and benefits as explained

Patient Signature: _________________ Date: ____________ Witness Signature: _________________ Date: ____________ Surgeon Signature: _________________ Date: ____________