Comprehensive Plastic Surgery Treatment Agreement

Patient Information

Name: _________________________ Date of Birth: _________________ Medical Record #: ______________

1. CONSENT TO TREATMENT

I, ______________________, hereby authorize Dr. ______________________ and associates to perform the following plastic surgery procedure(s):

2. NATURE OF PROCEDURE

• I understand that the above procedure(s) has/have been explained to me in detail
• I have received detailed information about expected outcomes, risks, and alternatives
• I acknowledge that no guarantees have been made regarding final results

3. 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
• Need for revision surgery

4. FINANCIAL RESPONSIBILITIES

• I understand that I am responsible for all charges not covered by insurance
• Revision surgery costs, if needed, are my responsibility
• Cancellation fees may apply as per clinic policy

5. PHOTOGRAPHY CONSENT

I consent to the taking of photographs for:

• Medical documentation
• Teaching purposes
• Marketing materials (separate consent required)

6. POST-OPERATIVE CARE

I agree to:

• Follow all post-operative instructions
• Attend scheduled follow-up appointments
• Contact the office immediately for unexpected complications

7. ATTESTATION

I confirm that:

• I have read and understand this agreement
• All my questions have been answered satisfactorily
• I am not under the influence of any substances affecting my judgment

Patient Signature: _______________ Date: _______________ Witness Signature: _______________ Date: _______________ Surgeon Signature: _______________ Date: _______________