Liposuction - suction - ual

INFORMED CONSENT – LIPOSUCTION (Suction-Assisted Lipectomy Surgery)
(Ultrasound-Assisted Lipectomy Surgery)
INSTRUCTIONS
This is an informed-consent document that has been prepared to help inform you concerning liposuction surgery
(suction-assisted lipectomy and ultrasound-assisted lipectomy), its risks, and alternative treatment.
It is important that you read this information carefully and completely. Please initial each page, indicating that you
have read the page and sign the consent for surgery as proposed by Dr. Rothfield and agreed upon by you.
GENERAL INFORMATION
Liposuction is a surgical technique to remove unwanted deposits of fat from specific areas of the body, including
the face and neck, upper arms, trunk, abdomen, buttocks, hips and thighs, and the knees, calves and ankles.
This is not a substitute for weight reduction, but a method for removing localized deposits of fatty tissue that do
not respond to diet or exercise. Liposuction may be performed as a primary procedure for body contouring or
combined with other surgical techniques such as facelift, abdominoplasty, or thigh lift procedures to tighten loose
skin and supporting structures.
The best candidates for liposuction are individuals of relatively normal weight who have excess fat in particular
body areas. Having firm, elastic skin will result in a better final contour after liposuction. Skin that has diminished
tone due to stretch marks, weight loss, or natural aging will not reshape itself to the new contours and may
require additional surgical techniques to remove and tighten excess skin. Body-contour irregularities due to
structures other than fat cannot be improved by this technique. Liposuction by itself will not improve areas of
dimpled skin known as “cellulite.”
Suction-assisted lipectomy surgery is performed by using a hollow metal surgical instrument known as a
cannula that is inserted through small skin incision(s) and is passed back and forth through the area of fatty
deposit. The cannula is attached to a vacuum source, which provides the suction needed to remove the fatty
tissue.
In some situations, a special cannula may be used that emits ultrasonic energy to break down fatty deposits. This
technique is known as ultrasound-assisted lipectomy. Depending on your needs, Dr. Rothfield may
recommend suction-assisted lipectomy alone, or in combination with ultrasound-assisted lipectomy.
There are a variety of different techniques used by plastic surgeons for liposuction and care following surgery.
Liposuction may be performed under local or general anesthesia. Tumescent liposuction technique involves
the infiltration of fluid containing dilute local anesthetic and epinephrine into areas of fatty deposits. This technique
can reduce discomfort at the time of surgery, blood loss, and post-operative bruising.
Support garments and dressings are worn to control swelling and promote healing.
ALTERNATIVE TREATMENTS
Alternative forms of management consist of not treating the areas of fatty deposits. Diet and exercise regimens
may be of benefit in the overall reduction of excess body fat. Direct removal of excess skin and fatty tissue may
be necessary in addition to liposuction in some patients. Risks and potential complications are associated with
alternative surgical forms of treatment.

RISKS OF LIPOSUCTION SURGERY
Every surgical procedure involves a certain amount of risk and it is important that you understand these risks and
the possible complications associated with them. In addition, every procedure has limitations. An individual’s
choice to undergo a surgical procedure is based on the comparison of the risk to potential benefit. Although the
majority of patients do not experience these complications, you should discuss each of them with Dr. Rothfield to
make sure you completely understand all possible consequences of liposuction.
Specific Risks of Liposuction

Page 1 of 9
Patient Initials
05-09-2009 version
2009 American Society of Plastic Surgeons INFORMED CONSENT – LIPOSUCTION (Suction-Assisted Lipectomy Surgery)
(Ultrasound-Assisted Lipectomy Surgery)
Patient Selection: Individuals with poor skin tone, medical problems, obesity, or unrealistic expectations may not
be candidates for liposuction.
Pubic Distortion: It is possible, though unusual, for women to develop distortion of their labia and pubic area.
Should this occur, additional treatment including surgery may be necessary.

Umbilicus: Malposition, scarring, unacceptable appearance or loss of the umbilicus (navel) may occur.

Tumescent Liposuction: There is the possibility that large volumes of fluid containing dilute local anesthetic
drugs and epinephrine that is injected into fatty deposits during surgery may contribute to fluid overload or
systemic reaction to these medications. Additional treatment including hospitalization may be necessary.

Ultrasound-Assisted Lipectomy: Risks associated with the use of this technique include the above mentioned
risks and the following specific risks:
Burns: Ultrasonic energy may produce burns and tissue damage either at the location where the cannula
is inserted into the skin or in other areas if the cannula touches the undersurface of the skin for prolonged
periods of time. If burns occur, additional treatment and surgery may be necessary.
Cannula Fragmentation: Ultrasonic energy produced within the cannula may cause disintegration
(fragmentation) of the surgical instrument. The occurrence and effect of this is unpredictable. Should this
occur, additional treatment including surgery may be necessary.
Unknown Risks:The long-term effect on tissue and organs to exposure to short-duration, high-intensity
ultrasonic energy is unknown. There is the possibility that additional risk factors of ultrasound-assisted
liposuction may be discovered.

General Risks of Surgery
Healing Issues: Certain medical conditions, dietary supplements and medications may delay and interfere with
healing. Patients with massive weight loss may have a healing delay that could result in the incisions coming
apart, infection, and tissue changes resulting in the need for additional medical care, surgery, and prolonged
hospitalizations. Patients with diabetes or those taking medications such as steroids on an extended basis may
have prolonged healing issues. Smoking will cause a delay in the healing process, often resulting in the need for
additional surgery. There are general risks associated with healing such as swelling, bleeding, and the length of
surgery and anesthesia that include a longer recovery and the possibility of additional surgery, prolonged
recovery, color changes, shape changes, infection, not meeting goals and expectations, and added expense to
the patient. Patients with significant skin laxity (patients seeking facelifts, breast lifts, abdominoplasty, and body
lifts) will continue to have the same lax skin after surgery. The quality or elasticity of skin will not change and
recurrence of skin looseness will occur at some time in the future, quicker for some than others. There are nerve
endings that may become involved with healing scars during surgery such as suction-assisted lipectomy,
abdominoplasty, facelifts, body lifts, and extremity surgery. While there may not be a major nerve injury, the small
nerve endings during the healing period may become too active producing a painful or oversensitive area due to
the small sensory nerve involved with scar tissue. Often massage and early non-surgical intervention resolves
this. It is important to discuss post-surgical pain with Dr. Rothfield.

Bleeding: It is possible, though unusual, to experience a bleeding episode during or after surgery. Should post-
operative bleeding occur, it may require emergency treatment to drain accumulated blood or you may require a
blood transfusion, though such occurrences are rare. Increased activity too soon after surgery can lead to
increased chance of bleeding and additional surgery. It is important to follow postoperative instructions and limit
exercise and strenuous activity for the instructed time. Do not take any aspirin or anti-inflammatory medications
for at least ten days before or after surgery, as this may increase the risk of bleeding. Non-prescription “herbs”
and dietary supplements can increase the risk of surgical bleeding. Hematoma can occur at any time, usually in
the first three weeks following injury to the operative area. If blood transfusions are necessary to treat blood loss,
there is the risk of blood-related infections such as hepatitis and HIV (AIDS). Heparin medications that are used
to prevent blood clots in veins can produce bleeding and decreased blood platelets.
Page 2 of 9
Patient Initials
05-09-2009 version
2009 American Society of Plastic Surgeons INFORMED CONSENT – LIPOSUCTION (Suction-Assisted Lipectomy Surgery)
(Ultrasound-Assisted Lipectomy Surgery)
Infection: Infection is unusual after surgery. Should an infection occur, additional treatment including antibiotics,
hospitalization, or additional surgery may be necessary. It is important to tell Dr. Rothfield of any other infections,
such as ingrown toenail, insect bite, or urinary tract infection. Remote infections, infections in other parts of the
body, may lead to an infection in the operated area.
Scarring: All surgery leaves scars, some more visible than others. Although good wound healing after a surgical
procedure is expected, abnormal scars may occur within the skin and deeper tissues. Scars may be unattractive
and of different color than the surrounding skin tone. Scar appearance may also vary within the same scar.
Scars may be asymmetrical (appear different on the right and left side of the body). There is the possibility of
visible marks in the skin from sutures. In some cases scars may require surgical revision or treatment.
Firmness: Excessive firmness can occur after surgery due to internal scarring. The occurrence of this is not
predictable. Additional treatment including surgery may be necessary.
Change in Skin Sensation: It is common to experience diminished (or loss) of skin sensation in areas that have
had surgery. Diminished (or complete loss of skin sensation) may not totally resolve.

Skin Contour Irregularities: Contour and shape irregularities may occur. Visible and palpable wrinkling of skin
may occur. Residual skin irregularities at the ends of the incisions or “dog ears” are always a possibility when
there is excessive redundant skin. This may improve with time, or it can be surgically corrected.
Skin Discoloration / Swelling: Some bruising and swelling normally occur. The skin in or near the surgical site
can appear either lighter or darker than surrounding skin. Although uncommon, swelling and skin discoloration
may persist for long periods of time and, in rare situations, may be permanent.
Skin Sensitivity: Itching, tenderness, or exaggerated responses to hot or cold temperatures may occur after
surgery. Usually this resolves during healing, but in rare situations it may be chronic.
Major Wound Separation: Wounds may separate after surgery. Should this occur, additional treatment including
surgery may be necessary.

Sutures: Most surgical techniques use deep sutures. You may notice these sutures after your surgery. Sutures
may spontaneously poke through the skin, become visible or produce irritation that requires suture removal.

Delayed Healing: Wound disruption or delayed wound healing is possible. Some areas of the skin may not heal
normally and may take a long time to heal. Areas of skin may die. This may require frequent dressing changes
or further surgery to remove the non-healed tissue. Individuals who have decreased blood supply to tissue from
past surgery or radiation therapy may be at increased risk for wound healing and poor surgical outcome.
Smokers have a greater risk of skin loss and wound healing complications.
Damage to Deeper Structures: There is the potential for injury to deeper structures including nerves, blood
vessels, muscles, and lungs (pneumothorax) during any surgical procedure. The potential for this to occur varies
according to the type of procedure being performed. Injury to deeper structures may be temporary or permanent.

Fat Necrosis: Fatty tissue found deep in the skin might die. This may produce areas of firmness within the skin.
Additional surgery to remove areas of fat necrosis may be necessary. There is the possibility of contour
irregularities in the skin that may result from fat necrosis.
Seroma: Infrequently, fluid may accumulate between the skin and the underlying tissues following surgery, trauma
or vigorous exercise. Should this problem occur, it may require additional procedures for drainage of fluid.

Surgical Anesthesia: Both local and general anesthesia involve risk. There is the possibility of complications,
injury, and even death from all forms of surgical anesthesia or sedation.
Shock: In rare circumstances, your surgical procedure can cause severe trauma, particularly when multiple or
extensive procedures are performed. Although serious complications are infrequent, infections or excessive fluid
Page 3 of 9
Patient Initials
05-09-2009 version
2009 American Society of Plastic Surgeons INFORMED CONSENT – LIPOSUCTION (Suction-Assisted Lipectomy Surgery)
(Ultrasound-Assisted Lipectomy Surgery)
loss can lead to severe illness and even death. If surgical shock occurs, hospitalization and additional treatment
would be necessary.

Pain: You will experience pain after your surgery. Pain of varying intensity and duration may occur and persist
after surgery. Chronic pain may occur very infrequently from nerves becoming trapped in scar tissue or due to
tissue stretching.
Cardiac and Pulmonary Complications: Pulmonary complications may occur secondarily to both blood clots
(pulmonary emboli), fat deposits (fat emboli) or partial collapse of the lungs after general anesthesia. Pulmonary
emboli can be life-threatening or fatal in some circumstances. Inactivity and other conditions may increase the
incidence of blood clots traveling to the lungs causing a major blood clot that may result in death. It is important
to discuss with Dr. Rothfield any past history of swelling in your legs or blood clots that may contribute to this
condition. Cardiac complications are a risk with any surgery and anesthesia, even in patients without symptoms.
If you experience shortness of breath, chest pain, or unusual heart beats, seek medical attention immediately.
Should any of these complications occur, you may require hospitalization and additional treatment.
Allergic Reactions: In rare cases, local allergies to tape, suture material and glues, blood products, topical
preparations or injected agents have been reported. Serious systemic reactions including shock (anaphylaxis)
may occur in response to drugs used during surgery and prescription medicines. Allergic reactions may require
additional treatment.

Asymmetry: Symmetrical body appearance may not result after surgery. Factors such as skin tone, fatty
deposits, skeletal prominence, and muscle tone may contribute to normal asymmetry in body features. Most
patients have differences between the right and left side of their bodies before any surgery is performed.
Additional surgery may be necessary to attempt to diminish asymmetry.
Surgical Wetting Solutions: There is the possibility that large volumes of fluid containing dilute local anesthetic
drugs and epinephrine that is injected into fatty deposits during surgery may contribute to fluid overload or
systemic reaction to these medications. Additional treatment including hospitalization may be necessary.
Persistent Swelling (Lymphedema): Persistent swelling in the legs can occur following surgery.
Unsatisfactory Result: Although good results are expected, there is no guarantee or warranty expressed or
implied, on the results that may be obtained. You may be disappointed with the results of surgery. Asymmetry,
unanticipated shape and size, loss of function, wound disruption, poor healing, and loss of sensation may occur
after surgery. Size may be incorrect. Unsatisfactory surgical scar location or appearance may occur. It may be
necessary to perform additional surgery to improve your results.
Page 4 of 9
Patient Initials
05-09-2009 version
2009 American Society of Plastic Surgeons INFORMED CONSENT – LIPOSUCTION (Suction-Assisted Lipectomy Surgery)
(Ultrasound-Assisted Lipectomy Surgery)
ADDITIONAL ADVISORIES

Smoking, Second-Hand Smoke Exposure, Nicotine Products (Patch, Gum, Nasal Spray):
Patients who are currently smoking or use tobacco or nicotine products (patch, gum, or nasal spray) are at a
greater risk for significant surgical complications of skin dying, delayed healing and additional scarring.
Individuals exposed to second-hand smoke are also at potential risk for similar complications attributable to
nicotine exposure. Additionally, smoking may have a significant negative effect on anesthesia and recovery from
anesthesia, with coughing and possibly increased bleeding. Individuals who are not exposed to tobacco smoke
or nicotine-containing products have a significantly lower risk of this type of complication. Please indicate your
current status regarding these items below:
___ I am a non-smoker and do not use nicotine products. I understand the potential risk of second-hand smoke
exposure causing surgical complications.
___ I am a smoker or use tobacco / nicotine products. I understand the risk of surgical complications due to
smoking or use of nicotine products.
___ I have smoked and stopped approximately _________ ago. I understand I may still have the effects and
therefore risks from smoking in my system, if not enough time has lapsed.

It is important to refrain from smoking at least 6 weeks before surgery and until Dr. Rothfield states it is safe to
return, if desired. I acknowledge that I will inform Dr. Rothfield if I continue to smoke within this time frame, and
understand that for my safety, the surgery, if possible, may be delayed.
Medications and Herbal Dietary Supplements: There are potential adverse reactions that occur as the result of
taking over-the-counter, herbal, and/or prescription medications. Aspirin and medications that contain aspirin
interfere with clotting and can cause more bleeding. These include non-steroidal anti-inflammatories such as
Motrin, Advil, and Alleve. It is very important not to stop drugs that interfere with platelets, such as Plavix, which is
used after a stent. It is important if you have had a stent and are taking Plavix that you inform Dr. Rothfield.
Stopping Plavix may result in a heart attack, stroke and even death. Be sure to check with your physician about
any drug interactions that may exist with medications that you are already taking. If you have an adverse
reaction, stop the drugs immediately and call Dr. Rothfield for further instructions. If the reaction is severe, go
immediately to the nearest emergency room. When taking the prescribed pain medications after surgery, realize
that they can affect your thought process and coordination. Do not drive, do not operate complex equipment, do
not make any important decisions and do not drink any alcohol while taking these medications. Be sure to take
your prescribed medication only as directed.

Sun Exposure – Direct or Tanning Salon: The effects of the sun are damaging to the skin. Exposing the treated
areas to sun may result in increased scarring, color changes, and poor healing. Patients who tan, either outdoors
or in a salon, should inform Dr. Rothfield and either delay treatment, or avoid tanning until Dr. Rothfield says it is
safe to resume. The damaging effect of sun exposure occurs even with the use sun block or clothing coverage.

Travel Plans: Any surgery holds the risk of complications that may delay healing and delay your return to normal
life. Please let Dr. Rothfield know of any travel plans, important commitments already scheduled or planned, or
time demands that are important to you, so that appropriate timing of surgery can occur. There are no guarantees
that you will be able to resume all activities in the desired time frame.
Long-Term Results: Subsequent alterations in the appearance of your body may occur as the result of aging,
sun exposure, weight loss, weight gain, pregnancy, menopause or other circumstances not related to your
surgery.
Body-Piercing Procedures: Individuals who currently wear body-piercing jewelry in the surgical region are
advised that an infection could develop from this activity.
Female Patient Information: It is important to inform Dr. Rothfield if you use birth control pills, estrogen
replacement, or if you suspect you may be pregnant. Many medications including antibiotics may neutralize the
preventive effect of birth control pills, allowing for conception and pregnancy.
Page 5 of 9
Patient Initials
05-09-2009 version
2009 American Society of Plastic Surgeons INFORMED CONSENT – LIPOSUCTION (Suction-Assisted Lipectomy Surgery)
(Ultrasound-Assisted Lipectomy Surgery)

Intimate Relations After Surgery: Surgery involves coagulating of blood vessels and increased activity of any
kind may open these vessels leading to a bleed, or hematoma. Activity that increases your pulse or heart rate
may cause additional bruising, swelling, and the need for return to surgery and control bleeding. It is wise to
refrain from intimate physical activities until Dr. Rothfield states it is safe.

Mental Health Disorders and Elective Surgery: It is important that all patients seeking to undergo elective
surgery have realistic expectations that focus on improvement rather than perfection. Complications or less than
satisfactory results are sometimes unavoidable, may require additional surgery and often are stressful. Please
openly discuss with Dr. Rothfield, prior to surgery, any history that you may have of significant emotional
depression or mental health disorders. Although many individuals may benefit psychologically from the results of
elective surgery, effects on mental health cannot be accurately predicted.

Metabolic Status of Massive Weight Loss Patients: Your personal metabolic status of blood chemistry and
protein levels may be abnormal following massive weight loss and surgical procedures to make a patient loose
weight. Individuals with abnormalities may be at risk for serious medical and surgical complications, including
delayed wound healing, infection or even in rare cases, death.


ADDITIONAL SURGERY NECESSARY (Re-Operations)
There are many variable conditions that may influence the long-term result of surgery. It is unknown how your
tissue may respond or how wound healing will occur after surgery. Secondary surgery may be necessary to
perform additional tightening or repositioning of body structures. Should complications occur, additional surgery
or other treatments may be necessary. Even though risks and complications occur infrequently, the risks cited
are particularly associated with this surgery. Other complications and risks can occur but are even more
uncommon. The practice of medicine and surgery is not an exact science. Although good results are expected,
there is no guarantee or warranty expressed or implied, on the results that may be obtained. In some situations, it
may not be possible to achieve optimal results with a single surgical procedure.

PATIENT COMPLIANCE
Follow all physician instructions carefully; this is essential for the success of your outcome. It is important that the
surgical incisions are not subjected to excessive force, swelling, abrasion, or motion during the time of healing.
Personal and vocational activity needs to be restricted. Protective dressings and drains should not be removed
unless instructed by Dr. Rothfield. Successful post-operative function depends on both surgery and subsequent
care. Physical activity that increases your pulse or heart rate may cause bruising, swelling, fluid accumulation
and the need for return to surgery. It is wise to refrain from intimate physical activities after surgery until Dr.
Rothfield states it is safe. It is important that you participate in follow-up care, return for aftercare, and promote
your recovery after surgery.

HEALTH INSURANCE
Most health insurance companies exclude coverage for cosmetic surgical operations or any resulting
complications. Please carefully review your health insurance subscriber-information pamphlet. Most insurance
plans exclude coverage for secondary or revisionary surgery due to complications of cosmetic surgery.
Page 6 of 9
Patient Initials
05-09-2009 version
2009 American Society of Plastic Surgeons INFORMED CONSENT – LIPOSUCTION (Suction-Assisted Lipectomy Surgery)
(Ultrasound-Assisted Lipectomy Surgery)
FINANCIAL RESPONSIBILITIES
The cost of surgery involves several charges for the services provided. The total includes fees charged by your
surgeon, the cost of surgical supplies, anesthesia, laboratory tests, and possible outpatient hospital charges,
depending on where the surgery is performed. Depending on whether the cost of surgery is covered by an
insurance plan, you will be responsible for necessary co-payments, deductibles, and charges not covered. The
fees charged for this procedure do not include any potential future costs for additional procedures that you elect to
have or require in order to revise, optimize, or complete your outcome. Additional costs may occur should
complications develop from the surgery. Secondary surgery or hospital day-surgery charges involved with
revision surgery will also be your responsibility. In signing the consent for this surgery/procedure, you
acknowledge that you have been informed about its risks and consequences and accept responsibility
for the clinical decisions that were made along with the financial costs of all future treatments.
___I understand that with cosmetic surgery, I am responsible for the surgical fees quoted to me, as well as
additional fees for anesthesia, facility (OR), and possibly laboratory, X-ray, and pathology fees.
Surgicenters, Outpatient Centers, and Hospitals often have rules that certain tissue/implants removed during
surgery must be sent for evaluation which may result in additional fees. Please check with your surgeon to
receive an estimate of any additional costs that you may be charged.
___I understand that there will be a non-refundable fee for booking and scheduling my surgery of $500, which is a
part of the overall surgical fee.
Should I cancel my surgery without an approved medically acceptable reason, submitted in writing and
acceptable to the practice, within 4 weeks of the scheduled surgery, this fee is forfeited. While this may appear to
be a charge for services which were not provided, this fee is necessary to reserve time in the OR and in the
practice, which are done when I schedule.
___ I understand and unconditionally and irrevocably accept this.

DISCLAIMER
Informed-consent documents are used to communicate information about the proposed surgical treatment of a
disease or condition along with disclosure of risks and alternative forms of treatment(s), including no surgery. The
informed-consent process attempts to define principles of risk disclosure that should generally meet the needs of
most patients in most circumstances.
However, informed-consent documents should not be considered all-inclusive in defining other methods of care
and risks encountered. Dr. Rothfield may provide you with additional or different information which is based on all
the facts in your particular case and the current state of medical knowledge.
Informed-consent documents are not intended to define or serve as the standard of medical care. Standards of
medical care are determined on the basis of all of the facts involved in an individual case and are subject to
change as scientific knowledge and technology advance and as practice patterns evolve.

It is important that you read the above information carefully and have all of your
questions answered before signing the consent on the next page.

Page 7 of 9
Patient Initials
05-09-2009 version
2009 American Society of Plastic Surgeons INFORMED CONSENT – LIPOSUCTION (Suction-Assisted Lipectomy Surgery)
(Ultrasound-Assisted Lipectomy Surgery)
CONSENT FOR SURGERY / PROCEDURE or TREATMENT
1. I hereby authorize Dr. Robert E. Rothfield and such assistants as may be selected to perform the following procedure or treatment: LIPOSUCTION (Suction-Assisted Lipectomy Surgery, Ultrasound-Assisted
Lipectomy Surgery)
I have received the following information sheet: INFORMED CONSENT – LIPOSUCTION
2. I recognize that during the course of the operation and medical treatment or anesthesia, unforeseen conditions may necessitate different procedures than those above. I therefore authorize the above physician and assistants or designees to perform such other procedures that are in the exercise of his or her professional judgment necessary and desirable. The authority granted under this paragraph shall include all conditions that require treatment and are not known to my physician at the time the procedure is begun. 3. I consent to the administration of such anesthetics considered necessary or advisable. I understand that all forms of anesthesia involve risk and the possibility of complications, injury, and sometimes death. 4. I understand what Dr. Rothfield can and cannot do, and I understand there are no warranties or guarantees, implied or specific about my outcome. I have had the opportunity to explain my goals and understand which desired outcomes are realistic and which are not. All of my questions have been answered, and I understand the inherent (specific) risks to the procedures I seek, as well as those additional risks and complications, benefits, and alternatives. Understanding all of this, I elect to proceed. 5. I consent to be photographed or televised before, during, and after the operation(s) or procedure(s) to be performed, including appropriate portions of my body, for medical, scientific or educational purposes, provided my identity is not revealed by the pictures. 6. For purposes of advancing medical education, I consent to the admittance of observers to the operating 7. I consent to the disposal of any tissue, medical devices or body parts which may be removed. 8. I consent to the utilization of blood products should they be deemed necessary by my surgeon and/or his/her appointees, and I am aware that there are potential significant risks to my health with their utilization. 9. I authorize the release of my Social Security number to appropriate agencies for legal reporting and medical- 10. I understand that the surgeon’s fees are separate from the anesthesia and hospital charges, and the fees are agreeable to me. If a secondary procedure is necessary, further expenditure will be required. 11. I realize that not having the operation is an option. 12. IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND: a. THE ABOVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN b. THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT c. THERE ARE RISKS TO THE PROCEDURE OR TREATMENT PROPOSED I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED ITEMS (1-12). __________________________________________________________________________ Patient or Person Authorized to Sign for Patient Date __________________________ Witness ____________________________________ Page 8 of 9
Patient Initials
05-09-2009 version
2009 American Society of Plastic Surgeons

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