Pure Lipo Sculpt Center - Consolidated Patient Forms

Transcription

1 Pure Lip Sculpt Center - Cnslidated Patient Frms 1) Cnsultatin Frm 2) Infrmed Cnsent Liplysis 3) Phtgraphy Authrizatin 4) Smking Cnsent 5) Minr Prcedure Patient Checklist 6) Pst-Op Instructins 7) Infrmed Cnsent Fr Fat Transfer 8) Fees Cst and Cancellatin Cnsultatin Infrmatin Client Name: Client Address: Apt/Unit #: City: State: Zip Cde: Phne: ( ) Hme ( ) Wrk ( ) Cell Birthday(mm/dd/yyyy): ( ) Under 21 ( ) ( ) ( ) ( ) Over 50 Height: Weight: Address: Hw did yu hear abut us? (phne bk, newspaper, radi, T.V., mailers, wrd f muth ther) Client Prfile 1. MEDICATIONS: 2. ALLERGIES: 3. Have yu undergne any surgery in the last 9 mnths? (Including plastic r csmetic). ( ) Yes ( ) N If yes, what details can yu prvide?

2 4. Have yu been under a physician's care in the last 12 mnths. ( ) Yes ( ) N 5. List all vitamins: 6. Have yu had any f these health prblems? Past r present ( ) Cancer ( ) Heart prblems ( ) Diabetes ( ) Varicse veins ( ) Epilepsy ( ) Herpes simplex ( ) Thyrid ( ) High bld pressure ( ) Aids/HIV ( ) Hepatitis (B r C) ( ) Hrmne imbalance ( ) Hysterectmy ( ) Bld clts 7. Have any f yur family members had any f these health prblems? Past r present ( ) Cancer ( ) Heart prblems ( ) Diabetes ( ) Varicse veins ( ) Epilepsy ( ) Herpes simplex ( ) Thyrid ( ) High bld pressure ( ) Aids/HIV ( ) Hepatitis (B r C) ( ) Hrmne imbalance ( ) Hysterectmy ( ) Bld clts 8. D yu... Cnsume a lt f dairy? Cnsume a lt f salt? Fllw a strict diet? Smke? ( ) Yes ( ) N ( ) Yes ( ) N ( ) Yes ( ) N ( ) Yes ( ) N

3 Use Retin-A? Ever taken Accutane? Exercise regularly? Wear cntact lenses? Regular sleep patterns? ( ) Yes ( ) N ( ) Yes ( ) N ( ) Yes ( ) N ( ) Yes ( ) N ( ) Yes ( ) N 9. D yu have special cncerns abut yur face/ bdy? ( ) Yes ( ) N If yes what kind? 10. Have yu ever had a face r bdy treatment befre? ( ) Yes ( ) N If yes, which treatment? 11. Are yu taking ral cntraceptin? ( ) Yes ( ) N 12. Are yu pregnant, r trying t get pregnant? ( ) Yes ( ) N I cnfirm, t the best f my knwledge, the answers I have given are crrect and I have nt withheld any infrmatin that may be relevant t my treatment. RELEASE AND CONSENT AGREEMENT: I,, acknwledge that I have been advised and fully infrmed cncerning the nature f the prcedures t be administered by the staff f Pure LipSculpt Center including but nt limited t pssible cmplicatins assciated with such prcedures. I represent that the answers I have given t the questins n the histry card are true and crrect. I understand that the emplyees f Pure LipSculpt Center are relying n the truthfulness and accuracy f such statements in determining which prcedures are apprpriate fr me. I herby authrize and direct the staff Pure LipSculpt Center t perfrm the prcedures. I fully understand that the administratin f the prcedures, t which I am cnsenting, is nt an exact science. I hereby cnfirm that n warranty r guarantee, r ther assurances have been made t me cvering the prcess r results f the prcedure. I understand that there shall be NO REFUNDS ON ANY TREATMENT. I hereby

4 release and hld harmless Pure LipSculpt Center, it's emplyees, agents, independent cntractrs, directrs, and fficers frm and against all claims, demands, damages, cst, expenses, and liability fr injury r damage that may ccur t me arising ut f r in any way cnnected with the perfrmance f the prcedures. My signature belw cnstitutes my acknwledgement that I have read, understand, and fully agree t the freging WAIVER and CONSENT, the prcedures have been satisfactrily explained t me and I have all f the infrmatin which I desire. I hereby give my authrizatin and cnsent t the perfrmance f such prcedure(s). Infrmed Cnsent fr Laser Liplysis Instructins This infrmed cnsent prvides yu with infrmatin cncerning yur suctin-assisted laser liplysis surgery and its risks. General Infrmatin Liplysis is csmetic surgery perfrmed t remve unwanted depsits f fat frm specific areas f the bdy, including the face and neck, upper arms, trunk, abdmen, buttcks, hips and thighs, and the knees, calves and ankles. Yur dctr will sculpt and recntur yur bdy by remving excess fat depsits that have been resistant t reductin by diet r exercise. Liplysis may be perfrmed as a primary prcedure fr bdy cnturing r cmbined with ther surgical prcedures such as abdminplasty, facelift, r thigh lift prcedures t tighten lse skin and supprting structures. The ideal candidates fr liplysis are individuals f relatively nrmal weight wh have excess fat in particular bdy areas. Having firm, elastic skin will result in a better final cntur after this prcedure. Skin that has diminished tne due t natural aging, stretch marks r weight lss will nt reshape itself t the new cnturs and may require additinal surgical techniques t remve and tighten excess skin. Suctin-assisted laser liplysis surgery is perfrmed by using a hllw metal surgical instrument knwn as a cannula carrying a laser delivery fiber that is inserted thrugh small skin incisin(s) and is passed back and frth thrugh the area f fatty depsit as the laser is activated. The cannula attached t a vacuum surce is then used t aspirate the fatty depsits. The prcedure will use Nd:YAG laser with wavelength f 1064nm and/r 1319nm* depending n physicians preference. It may be perfrmed under lcal r general anesthesia. After surgery, supprt garments and dressings are wrn t cntrl swelling and prmte healing. * 1064nm is cleared by FDA fr laser liplysis;

5 Treatment Alternatives Treatment alternatives are nt treating the fatty depsits, diet and exercise t reduce unwanted fat r ther methds surgical remval f fatty depsits (including ultrasnic lipsuctin). Varying degree f risks and cmplicatins are assciated with these treatment alternatives. Risks Of Lipsuctin Surgery Every medical prcedure invlves a certain amunt f risk and every prcedure has limitatins. Yur chice t underg a surgical prcedure is based n the cmparisn f the risk t ptential benefit. Althugh the majrity f patients d nt experience these cmplicatins, yu shuld discuss each f them with yur plastic surgen t make sure yu cmpletely understand all pssible cnsequences f liplysis. Infectin: Shuld an infectin ccur, additinal treatment including antibitics, hspitalizatin, r additinal surgery may be necessary. Bleeding: If bld transfusin is needed t treat bld lss, there is a risk f bld-related infectins. Patient Selectin: Patients with pr medical health may nt be candidates fr lipsuctin. Scarring: All surgery leaves scars within the skin and deeper tissue. Sme scars are mre visible than thers. Lss in Skin Sensatin: Lss f skin sensatin may ccur which may r may nt ttally reslve. Skin Swelling/Disclratin: Bruising and swelling f skin near the surgical site nrmally ccurs fllwing lipsuctin. Irregular Skin Cntur: Skin cntur irregularities may ccur after lipsuctin. Asymmetry: Additinal surgery may be necessary t imprve asymmetry. Serma: Additinal treatments t drain accumulatins f fluid may be necessary. Surgical Anesthesia: There is risk f cmplicatins, injury, and even death frm all frms f surgical anesthesia. Pain: Pain f varying intensity and duratin may ccur and persist after lipsuctin surgery. Skin Sensitivity: Yu may experience increased skin sensitivity after surgery. Deeper Structure Damages: The ptential fr this t ccur varies accrding t the type f prcedure being perfrmed. Injury t deeper structures may be temprary r permanent. Healing Delay: Delayed wund healing and wund disruptin can ccur and may take lnger t heal.

6 Allergic Reactins: Adverse reactins may ccur t drugs used during surgery and prescriptin medicatins after surgery. Fat Necrsis: Fatty tissue fund deep in the skin might die and may prduce areas f firmness within the skin which may require additinal surgery t remve areas f fat necrsis. Pubic Distrtin: Althugh rare, it is pssible that wmen may t develp distrtin f their labia and pubic area. Additinal treatment including surgery may be necessary shuld this ccur. Umbilicus Distrtin: Change in appearance r lss f the umbilicus (navel) may ccur. Persistent Swelling (Lymph edema): Persistent swelling in the legs can ccur fllwing lipsuctin. Surgical Shck: Individuals underging liplysis where a large vlume f fat is remved are at greater risk f cmplicatins. In rare circumstances, extensive liplysis can cause severe trauma and even death can ccur. Hspitalizatin and additinal treatment wuld be necessary if surgical shck ccurs after surgery. Deep Venus Thrmbsis, Cardiac and Pulmnary Cmplicatins: Past histry f bld clts, swllen legs r the use f estrgen r birth cntrl pills that may increase yur risk fr these cmplicatins. Tumescent Anesthesia: There is the pssibility that large vlumes f fluid injected int the fatty tissue may result in systemic reactin t these medicatins. Laser-Assisted Liplysis: Prlnged expsure f laser energy can prduce excessive tissue damage (burn) which may require additinal treatment and surgery. The lng-term effect n tissue and rgans t expsure t laser energy frm the 1064nm and 1319nm wavelengths is unknwn. It is pssible that additinal risk factrs f laser-assisted liplysis may be discvered in the future. Fat Transfer: Fat transfer can lead t swelling, bruising, & even infectins similar t lipsuctin. Irregularities, vercrrectin and under crrectin can ccur as well. Unsatisfactry Results Althugh satisfactry results are expected, there is n guarantee expressed r implied, n the results that may be btained. Risks pinted ut abve can ccur. It may nt be pssible t imprve the adverse effects f surgery. Additinal Advisries Medicatins: Discuss with yur surgen any drug interactins that may exist with medicatins which yu are already taking. Take yur medicatin as directed by yur surgen. Lng-Term Results: As yu age, changes in bdy appearance will ccur based n circumstances such as weight

7 lss/gain, sun expsure, pregnancy and menpause that is nt related t this surgery. Metablic Status f Massive Weight Lss Patients: Individuals with metablic abnrmalities may be at risk fr serius medical and surgical cmplicatins, including delayed wund healing, infectin r even in rare cases, death. Female Patient Infrmatin: Infrm yur surgen if yu use birth cntrl pills, estrgen replacement, r if yu believe yu may be pregnant. Many medicatins including antibitics may neutralize the preventive effect f birth cntrl pills, allwing fr cnceptin and pregnancy. Intimate Relatins After Surgery: Refrain frm sexual activity until yur physician states it is safe. Mental Health Disrders and Elective Surgery: Prir t surgery, discuss emtinal depressin r mental health disrders with yur surgen. There may be psychlgical benefit frm this surgery, but effects n mental health may nt be accurately predicted. Smking and Nictine Prducts Expsure: Patients wh smke are at greater risk fr cmplicatins f skin dying, delayed healing, additinal scarring and negative effect n anesthesia and recvery frm anesthesia. Please indicate yur current status: I d nt use smke and d nt use nictine prducts. I am a smker r use nictine prducts. I understand the risk f surgical cmplicatins due t smking and use f nictine prducts. Please refrain frm smking at least 4 weeks befre surgery and until yur physician states it is safe t return, if desired. Additinal Surgery Necessity Medical practice is nt an exact science. Additinal surgery may becme necessary if cmplicatins ccur. Althugh satisfactry results are expected, there is n warranty expressed r implied, n the results that may be btained. Patient Cmpliance Fllw all physician instructins carefully. Restrict physical activity and avid subjecting surgical site t excessive frce during the healing perid. D nt remve prtective dressings and drains unless instructed by yur physician. Nt fllwing up with physician fr all fllw up appintments will increase risk r cmplicatins. Health Insurance Mst health insurance cmpanies exclude cverage fr surgical peratins such as liplysis r any cmplicatins that might ccur frm surgery. Cntact yur insurance cmpany fr a detailed explanatin f their plicies. Financial Respnsibilities The cst f surgery includes fees charged by yur surgen, the cst f surgical supplies, anesthesia, labratry tests, and pssible utpatient hspital charges, depending n where the surgery is perfrmed. The fees charged fr this prcedure d nt include any ptential future csts fr additinal prcedures that yu elect t have r require in rder t revise, ptimize, r cmplete yur utcme. Additinal csts may ccur shuld cmplicatins develp frm the surgery. Secndary

8 surgery r hspital day-surgery charges invlved with revisin surgery will als be yur respnsibility. In signing the cnsent fr this surgery, yu acknwledge that yu have been infrmed abut its risk and cnsequences and accept respnsibility fr the clinical decisins that were made alng with the financial csts f all future treatments. Disclaimer Infrmed-cnsent dcuments are used t cmmunicate infrmatin abut the prpsed surgical treatment f a disease r cnditin alng with disclsure f risks and alternative frms f treatment(s), including n surgery. The infrmed-cnsent prcess attempts t define principles f risk disclsure that shuld generally meet the needs f mst patients in mst circumstances. Hwever, infrmed-cnsent dcuments shuld nt be cnsidered all inclusive in defining ther methds f care and risks encuntered. Yur surgen may prvide yu with additinal r different infrmatin which is based n all the facts in yur particular case and the current state f medical knwledge. Infrmed-cnsent dcuments are nt intended t define r serve as the standard f medical care. Standards f medical care are determined n the basis f all f the facts invlved in an individual case and are subject t change as scientific knwledge and technlgy advance and as practice patterns evlve. It is imprtant that yu read the abve infrmatin carefully and have all f yur questins answered befre signing the cnsent belw. Cnsent Fr Liplysis Cnsent Prcedure Or Treatment 1. I hereby authrize Dr. Denzel and such assistants as may be selected t perfrm the fllwing prcedure r treatment: Laser Assisted Liplysis with Aspiratin. 2. I recgnize that during the curse f the peratin and medical treatment r anesthesia, unfreseen cnditins may necessitate different prcedures than thse abve. I therefre authrize the abve physician and assistants r designees t perfrm such ther prcedures that are in the exercise f his r her prfessinal judgment necessary and desirable. The authrity granted under this paragraph shall include all cnditins that require treatment and are nt knwn t my physician at the time the prcedure is begun. 3. I cnsent t the administratin f such anesthetics cnsidered necessary r advisable. I understand that all frms f anesthesia invlve risk and the pssibility f cmplicatins, injury, and smetimes death.

9 4. I acknwledge that n guarantee r representatin has been given by anyne as t the results that may be btained. 5. I cnsent t be phtgraphed r televised befre, during, and after the peratin(s) r prcedure(s) t be perfrmed, including apprpriate prtins f my bdy, fr medical, scientific r educatinal purpses, prvided my identity is nt revealed by the pictures. 6. Fr purpses f advancing medical educatin, I cnsent t the admittance f bservers t the perating rm. 7. I cnsent t the dispsal f any tissue, medical devices r bdy parts which may be remved. 8. I cnsent t the utilizatin f bld prducts shuld they be deemed necessary by my surgen and/r his/her appintees, and I am aware that there are ptential significant risks t my health with their utilizatin. 9. I authrize the release f my Scial Security number t apprpriate agencies fr legal reprting and medical-device registratin, if applicable. 10. I understand that the surgens' fees are separate frm the anesthesia and hspital charges, and the fees are agreeable t me. If a secndary prcedure is necessary, further expenditure will be required. 11. I realize that nt having the peratin is an ptin. 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). I AM SATISFIED WITH THE EXPLANATION. initial Phtgraphy Authrizatin The use f phtgraphs is essential t the planning and evaluatin f csmetic surgery. Yur surgery will be phtgraphically dcumented befre, pssibly during and after the prcedure. These phtgraphs are a permanent part f yur medical recrd and will never be shwn t anyne else withut yur cnsent. Fr varius reasns yur dctr is ften asked t shw befre and after phts f patients. Many patients, happy with their results, have given permissin t use their phts annymusly. We nw

10 ask that yu d s as well. I recgnize that prspective patients, such as me, will ask t lk at befre and after phtgraphs in the prcess f chsing a surgen and evaluating specific prcedures. I authrize the annymus use f my phtgraphs fr this purpse by my dctr. initial I authrize the annymus use f my phtgraphs in seminars, health fairs and cnferences fr interested and/r prspective patients. initial I authrize the annymus use f my phtgraphs n the internet. initial I authrize the annymus use f my phtgraphs in advertisements. initial I understand that every attempt will be made t represent me and my dctr accurately and with integrity and dignity in all media. initial Tbacc Smkers and Scial Drugs Cnsent I understand that tbacc smking increases health risks. My dctr and his staff have advised me t stp smking. I will discntinue all smking fr six mnths befre and six mnths after my surgery. It has been explained t me that there is a decreased circulatin secndary t smking f tbacc and/r marijuana and that this can cause a delay in wund healing as well as skin breakdwn, skin lss and scarring. I agree t have a urine screening test fr tbacc prducts during the preperative perid t cnfirm my cmpliance t a prgram f nn-smking. I als agree t the same urine screening tests during the pstperative perid as my dctr deems necessary (i.e., wund r healing prblems). As a smker, I understand that the surgery will have t be mre cnservative and less aggressive than usual t try t avid these cmplicatins, which may still ccur, despite the dctr's best effrts t avid them. This has been fully explained t me, and I relieve my dctr frm any respnsibility related t the increased risks frm my smking habits. I am a nn-smker f tbacc. initial

11 I d nt use scial drugs. initial Minr Prcedure Patient Checklist D nt take aspirin, Advil, Mtrin r Ibuprfen within tw weeks prir t prcedure date r ne week after. Yu shuld arrange transprtatin fr after yur prcedure. Yur ride may wait here fr yu r they can leave their cntact infrmatin and we can call them when yur prcedure is clse t being finished. Yu shuld have eaten a full meal befre yu arrive fr yur prcedure. The medicatins yu will be taking can cause an upset stmach and vmiting if yu take them n an empty stmach. Wear lse and cmfrtable clthing fr after yur prcedure. Yu may shwer with assistance later that same day if needed. Remember... nly walking activity fr the first tw weeks. We will advance yur activity n a patient and recvery basis. Please d nt massage the areas until yur dctr says it is k t d s. Yu may have been given a garment. Garments help with cmfrt, pain and swelling. Yu will wear it fr up t tw weeks. Sme surgical areas and patients are nt given garments fr specific reasns. If yu were nt given a garment, please d nt be alarmed. This decisin is fr yur best recvery. Please limit r discntinue yur intake f the fllwing items, ne day prir t yur prcedure, t imprve yur recvery: salt, cffee, sugar, green tea and alchl. Pst-p Instructins Fr Bdy Cnturing Patients 1. INCISIONS: Incisins can appear several different ways: It may be clsed with a small stitch which will be remved abut ne week after surgery. It may have a drain inserted int the site and sutured int place (refer t DRAIN sectin). It may be left pen in rder fr the fluid t drain ut n its wn. One shuld expect a large vlume f bld-tinged anesthetic slutin t drain frm the incisin sites during the first 24 hurs. This will vary frm patient t patient. In general, the mre drainage there is, the less bruising and the swelling there will be. Yu may have a few

12 incisins drain fr up t a week. Even thugh the fluid is red, it is nly abut 1% bld with the remainder being lcal anesthetic and saline. Maxi-pads are recmmended fr bandages ver yur drainage sites. These pads must be changed every 4-6 hurs t prevent infectin. Many patients have fund it helpful t utilize a shwer curtain r ther prtective pad n their mattress, underneath the sheets fr the first several days after Bdy cnturing prcedures. 2. SHOWER: Yu may shwer 24 hurs after yur surgery. If yu have drains, put a lng she lace r pantyhse arund yur neck and safety pin the drains t that. 3. MEDICATIONS: Pst-p medicatins have been prescribed. Cephalexin (antibitic) begin taking immediately fllwing yur surgery. Perccet r Vicdin/Hydrcdne shuld be taken as needed fr pain. Yu may switch t Tylenl fr pain cntrl at yur discretin. D nt cmbine Tylenl with Perccet r Vicdin. Phenergan can be taken if yu experience nausea. Celebrex will help with inflammatin. If yu d experience nausea r vmiting it is prbably frm t the medicatin. Please try t take medicatin with fd. If it persists, please cntact ur ffice. Lunesta r Ambien is a sleeping pill and may be taken at night fr a full 8 hurs sleep. Yu may experience a metallic taste in yur muth frm Lunesta. DO NOT take any Ibuprfen based medicatins fr 2 weeks prir r 1 week after yur prcedure. If yu are unable t take any f these medicatins, please cntact ur ffice s we can arrange fr ther medicatins. 4. DIET: There are n dietary restrictins. Drink plenty f clear fluids. We recmmend 8 glasses f water a day. We suggest yu limit items that cntain high levels f sdium such as sups. This will nly increase yur fluid retentin. 5. COMMON SIDE EFFECTS: A cllectin f fluid may develp under the skin and have a "waterbed" appearance. It may make yu feel mre uncmfrtable and swllen. If this ccurs, please call us. It is smething we can easily address in the ffice. If yu have surgery n yur lwer extremities, yu may experience additinal swelling in yur lwer legs, calves and ankles. T minimize the swelling, keep yur legs elevated as much as pssible fr the first 2 weeks. Menstrual irregularities with premature r delayed nset f mnthly menstruatin are a cmmn side effect f any significant surgery. Flushing f the face, neck and upper chest may ccur after lipsuctin and may last fr a day r tw. Slight temperature elevatin during the first 48 hurs after surgery is a natural cnsequence f the bdy's reactin t surgical trauma.

13 Bruising varies between each patient. The mre extensive the LipSelectin, the mre bruising ne can expect. If yu experience cnstipatin it is prbably due t the medicatin. Please try t increase yur intake f prunes, fiber, and clear fluids. If it persists, please cntact the ffice. Males and females may experience significant swelling in the pubic regin after lwer abdminal lipsuctin. Males may need t purchase an Athletic Supprt Garment fr significant genital swelling and elevatin f the scrtum is recmmended. 6. ACTIVITY: Rest fr the first 24 hurs. Yu may resume yur nrmal activities as tlerated. If yu experience mre than mild swelling r discmfrt yu may be ver ding it. This will nt hwever affect the results f yur surgery. During the first 1-2 weeks, walking is acceptable and encuraged. Once yur dctr releases yu, abut 2-3 weeks after surgery, yu can return t strenuus activities r aerbic exercise. 7. SORENESS: Pst-perative discmfrt usually takes the frm f deep muscle sreness and usually imprves ver 2-7days. It is nrmal t have a pulling r pinching sensatin fr weeks and smetimes mnths fllwing surgery. The surgical area may feel numb and yu may start t feel lumps r bands f cllagen. This is part f the healing prcess. Stretching is strngly advised and helpful. While stretching, yu may feel a ripping sensatin. This is nrmal and yu shuld cntinue with the stretch and wrk thrugh it. 8. MASSAGE: Therapeutic massage is very helpful t speed the healing prcess. Massage may be dne as ften as every day and as hard as yu can tlerate beginning 1 week after surgery. Whirl-pls and ht tubs are permitted nly after yur incisin sites have clsed. This is usually at least ne week after surgery. 9. EMOTIONAL RESPONSE: Yu may experience mild depressin the first week after surgery. After this time yur md will imprve after yu see the swelling and bruising fade. 10. NO SMOKING!!! 11. EXPOSURE TO SUNLIGHT: Scars take at least ne year t fade. During this time, yu must prtect them frm the sun. Even thrugh a bathing suit, a gd deal f sunlight can reach the skin and cause damage. Wear sunscreen with a SPF f at least 15 at all times when in the sunshine. Be extremely careful if yu have areas f reduced sensitivity. The same rules apply fr tanning beds. 12. ICE & HEAT: Be careful when applying ice r heat t the surgical areas. Yu have a decreased perceptin f cld and ht t the treated areas. Even using a heated car seat culd ptentially cause a burn.

14 13. GARMENT: Yu may r may nt be given a garment t wear after yur surgery. If yu are given ne, wear it at all times (except when bathing) until yur dctr advices therwise. Please have smene assist yu when taking it n and ff fr the first cuple f days because yu may becme lightheaded. If the neck area was treated and yu were given a garment, yu must wear it 24 hurs a day fr 3-4 days. DO NOT REMOVE IT FOR ANY REASON. Cntinue t wear it as much as pssible fr an additinal 4-7 days as directed by the physician. Supplies t have n hand: Shwer curtains t be placed ver yur car seat and mattress Maxi pads t place directly n wund site Wet-Ones t clean up bathrm Old set f sheets & blankets Bed pad r chux FYI: Prepare car seat, bed and pathway t restrm t prtect areas frm drainage. PLEASE REMEMBER THAT FOR THE MAJORITY OF PATIENTS THE GOAL IS SIGNIFICANT IMPROVEMENT, NOT PERFECTION. Infrmed Cnsent fr Fat Transfer Prcedures (Fat Grafts and Fat Injectins) Instructins This is an infrmed-cnsent dcument that has been prepared t help infrm yu cncerning fat transfer (fat grafts r fat injectin prcedures), its risks, and alternative treatments. It is imprtant that yu read this infrmatin carefully and cmpletely. Please initial each page, indicating that yu have read the page, and sign the cnsent fr the prcedure r surgery as prpsed by yur plastic surgen. Intrductin A persn's wn fat may be used t imprve the appearance f the bdy by mving it frm an area where it is less needed (usually the thights r abdmen) t an area that has lst tissue vlume due t aging, trauma, surgery, birth defects, r ther causes. Typically, the transferred fat results in an increase in vlume f the bdy site being treated. Befre the prcedure, the areas frm where the fat is being remved may be injected with a fluid t minimized bruising and discmfrt. The fat may be remved frm the bdy by a narrw surgical instrument (cannula) thrugh a small incisin r may be excised (cut ut) directly thrugh a larger incisin. In sme cases the fat may be prepared in a specific way befre being replaced back in the bdy. This preparatin may include washing,

15 filtering, and centrifugatin (spinning) f the fat. The fat is then placed int the desired area using either a smaller cannula r needle, r it may be placed directly thrugh an incisin. Since sme f the fat that is transferred des nt maintain its vlume ver time, yur surgen may inject mre than is needed at the time t achieve the desired end result. Over a few weeks, the amunt f transferred fat will decrease. At times, mre fat may need t be transferred t maintain the desired results. Fat transfer prcedures may be dne using a lcal anesthetic, sedatin, r general anesthesia depending n the extent f the prcedure. Alternative Treatments Alternative frms f nnsurgical and surgical management cnsist f injectins f man-made substances t imprve tissue vlume (such as hyanurnic acid, plylactic acid, etc.), use f manmade implants, r ther surgical prcedures that transfer fat frm the bdy (flaps). Risks and ptential cmplicatins are assciated with alternative frms f treatment. Risks Of Fat Transfer Prcedures Every prcedure invlves a certain amunt f risk, and it is imprtant that yu understand the risks invlved. An individual's chice t underg a prcedure is based n the cmparisn f the risk t its ptential benefit. Althugh the majrity f patients d nt experience these cmplicatins, yu shuld discuss each f them with yur plastic surgen t make sure yu understand the risks, ptential cmplicatins, and cnsequences f the prcedure. Bleeding: It is pssible, thugh unusual, t experience a bleeding episde during r after this prcedure. Shuld bleeding ccur, it may require emergency treatment t drain accumulated bld (hematma). D nt take any bld thining medicatins, aspirin, r nnsteridal antiinflammatry medicatins (acetaminphen is acceptable) fr ten days befre the prcedure, as these may cntribute t a greater risk f bleeding r significant bruising. Tell yur surgen if yu are n any f these medicatins befre stpping them. Serma: Althugh unlikely, a cllectin f fluid may appear at the site where the fat was remved. This is usually treated by draining the fluid with a needle. Infectin: Infectin is unusual after this prcedure. Shuld an infectin ccur, additinal treatment including antibitics r surgery may be necessary. Scarring: All invasive prcedures leave scars, sme mre visible than thers. Althugh gd wund healing after a prcedure is expected, abnrmal scars may ccur bth within the skin and in the deeper tissues. Scars may be unattractive and f different clr than the surrunding skin. There is the pssibility f visible marks frm sutures used t clse the wund. Scars may als limit mtin and functin. Additinal treatments including surgery may be needed t treat scarring. Change in Appearence: Typically the transferred fat lses sme f its vlume ver time and then becmes stable. It is pssible that mre treatments may be needed t maintain the

16 desired vlume f the transferred fat and resulting appearance. Less cmmnly, if yu experience significant weight gain, the transferred fat may increase in vlume and cause an undesirable appearance. It is imprtant t understand that mre than ne treatment may be needed and therefre t discuss with yur surgen the csts assciated f repeat treatments. Firmness and Lumpiness: While mst transferred fat results in a natural feel, it is pssible that sme r all f the fat may becme firm, hard, r lumpy. If sme f the fat des nt survive the transfer, it may result in fat necrsis (death f transferred fat tissue), causing firmess and discmfrt r pain. Cysts may als frm at the site f the transferred fat. Surgery may be required t imprve such cnditins. Asymmetry: Symmetrical bdy appearance may nt result frm a fat transfer prcedure. Factrs such as skin tne, fatty depsits, bny prminence, and muscle tne may cntribute t nrmal asymmetry in bdy features. Lng term effects: Subsequent changes in the shape r appearance f the area where the fat was remved r placed may ccur as the result f aging, weight lss r gain, r ther circumstances nt related t the fat transfer prcedure. Pain: Chrnic pain may ccur rarely after fat remval r transfer. Tissue Lss: In rare cases, the transferred fat may cause the skin ver the treated area t be injured resulting in lss f the skin and surrunding tissue. This may leave scars and disfigurement and require surgery fr treatment. Fat Transfer t Breasts: Fat transfer has been used t imprve the appearance f breasts recnstructed after cancer treatment, t imprve the appearance f breast defrmities, and t enlarge breasts fr csmetic purpses. While there is limited infrmatin regarding the lngterm implicatins f such prcedures, there are sme ptential cncerns especially with regards t breast cancer detectin. Since the transferred fat may becme firm and cause lumps, it may be necessary t have radilgical studies (mammgram, ultrasund, r MRI) perfrmed t be sure these lumps are nt due t cancer. It is als pssible that the firmness may make it mre difficult fr yu r yur dctr t examine the breasts. It is als pssible that a bipsy may be needed if there is cncern abut any abnrmal findings in yur breasts. Hwever, there is n reasn t believe that fat transfer prcedures may cause breast cancer. Damage t deeper structures: Deeper structures such as nerves, bld vessels, r muscles may be damaged during the curse f this prcedure. The ptential fr this t ccur varies accrding t where n the bdy the prcedure is being perfrmed. Injury t deeper structures may be temprary r permanent. Unsatisfactry result: There is the pssibility f an unsatisfactry result frm the prcedure, resulting in unacceptable visible defrmities, lss f functin, wund disruptin, skin death, r lss f sensatin. Yu may be disappinted with the results f the prcedure.

17 Allergic reactins: In rare cases, lcal allergies t tape, suture material, r tpical preparatins have been reprted. Systemic reactins, which are mre serius, may result frm drugs used during the prcedure r prescriptin medicines. Allergic reactins may require additinal treatment. Surgical anesthesia: Bth lcal and general anesthesia invlve risk. There is the pssibility f cmplicatins, injury, and even death frm all frms f surgical anesthesia r sedatin. Serius Cmplicatins: Althugh serius cmplicatins have been reprted t be assciated with fat transfer prcedures, these are very rare. Such cnditins include, but are nt limited t: Fat emblism (a piece f fat may find its way int the bld stream and result in a serius r life threatening cnditin), strke, meningitis (inflammatin f the brain), serius infectin, blindness r lss f visin, r death. Bld clts: Bld clts in the veins f the arms, legs, r pelvis may result frm frm fat transfer if it is dne as a surgical prcedure. These clts may cause prblems with the veins r may break ff and flw t the lungs where they may cause serius breathing prblems. Pulmnary cmplicatins: Pulmnary (lung and breathing) cmplicatins may ccur frm bth bld clts (pulmnary embli) and partial cllapse f the lungs after general anesthesia. Shuld either f these cmplicatins ccur, yu may require hspitalizatin and additinal treatment. Pulmnary embli can be life-threatening r fatal in sme circumstances. Fat emblism syndrme ccurs when fat drplets are trapped in the lungs. This is a very rare and pssibly fatal cmplicatin f fat transfer prcedures. Additinal Surgery Necessary In sme situatins, it may nt be pssible t achieve ptimal results with a single prcedure. Multiple prcedures may be necessary. Shuld cmplicatins ccur, surgery r ther treatments may be necessary. Even thugh risks and cmplicatins ccur infrequently, the risks cited abve are the nes that are particularly assciated with fat transfer prcedures. Other cmplicatins and risks can ccur but are even mre uncmmn. The practice f medicine and surgery is nt an exact science. Althugh gd results are expected, there cannt be any guarantee r warranty expressed r implied n the results that may be btained. Financial Respnsibilities The cst f the prcedure invlves several charges fr the services prvided. The ttal includes fees charged by yur dctr, the cst f surgical supplies, labratry tests, and pssible hspital charges, depending n where the surgery is perfrmed. Depending n whether the cst f the prcedure is cvered by an insurance plan, yu will be respnsible fr necessary c-payments, deductibles, and charges nt cvered. Additinal csts may ccur shuld cmplicatins develp frm the prcedure. Secndary surgery r hspital day-surgery charges invlved with revisinary surgery wuld als be

18 yur respnsibility. Disclaimer Infrmed-cnsent dcuments are used t cmmunicate infrmatin abut the prpsed treatment f a disease r cnditin alng with disclsure f risks and alternative frms f treatment(s). The infrmed-cnsent prcess attempts t define principles f risk disclsure that shuld generally meet the needs f mst patients in mst circumstances. Hwever, infrmed-cnsent dcuments shuld nt be cnsidered all inclusive in defining ther methds f care and risks encuntered. Yur plastic surgen may prvide yu with additinal r different infrmatin that is based n all the facts in yur particular case and the state f medical knwledge. Infrmed-cnsent dcuments are nt intended t define r serve as the standard f medical care. Standards f medical care are determined n the basis f all the facts invlved in an individual case and are subject t change as scientific knwledge and technlgy advance and as practice patterns evlve. It is imprtant that yu read the abve infrmatin carefully and have all f yur questins answered befre signing the cnsent n the next page. Cnsent Fr Surgery, Prcedure Or Treatment 1. I hereby authrize Dr. Denzel and such assistants as may be selected t perfrm the fllwing prcedure r treatment: Fat transfer including fat injectins and fat grafts 2. I have received the fllwing infrmatin sheet: INFORMED-CONSENT FAT TRANSFER PROCEDURES 3. I recgnize that during the curse f the peratin and medical treatment r anesthesia, unfreseen cnditins may necessitate different prcedures than thse abve. I therefre authrize the abve physician and assistants r designees t perfrm such ther prcedures that are in the exercise f his r her prfessinal judgment necessary and desirable. The authrity granted under this paragraph shall include all cnditins that require treatment and are nt knwn t my physician at the time the prcedure is begun. 4. I cnsent t the administratin f such anesthetics cnsidered necessary r advisable. I understand that all frms f anesthesia invlve risk and the pssibility f cmplicatins, injury, and smetimes death.

19 5. I acknwledge that n guarantee has been given by anyne as t the results that may be btained. 6. I cnsent t the phtgraphing r televising f the peratin(s) r prcedure(s) t be perfrmed, including apprpriate prtins f my bdy, fr medical, scientific r educatinal purpses, prvided my identity is nt revealed by the pictures. 7. Fr purpses f advancing medical educatin, I cnsent t the admittance f bservers t the perating rm. 8. I cnsent t the dispsal f any tissue, medical devices r bdy parts which may be remved. 9. I authrize the release f my Scial Security number t apprpriate agencies fr legal reprting and medical-device registratin, if applicable. 10. 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 (1-10). I AM SATISFIED WITH THE EXPLANATION. Fees, Cst & Cancellatin Financial Plicies Financial Plicies As patients apprach surgery, they inquire abut the varius payment ptins. We hpe the fllwing infrmatin will be helpful. Our patient crdinatrs are readily available t meet with yu persnally t prvide the specific infrmatin yu desire. Cnsultatins/Pst Op Visits A cnsultatin is free f charge with Dr. Denzel. There is als n charge fr any pst p visits. Hw T Secure A Surgical Date A depsit f $300 is required t bk yur surgery. This amunt will be deducted frm the remainder f the fees, which is due and payable tw weeks prir t yur surgery date, usually at yur preperative appintment. Credit Cards Visa, MasterCard, Discver r American Express are all acceptable frms f payment.

20 Cash Or Check Cashier's check, mney rder, bank cash r debit card is all acceptable frms f payment. Persnal checks are acceptable nly if they are certified. Cancellatin Plicy We understand that a situatin may arise that culd frce yu t pstpne yur surgery. Please understand that such changes affect nt nly yur dctr but ther patients as well. Dr. Denzel's time, as well as that f the prcedure rm staff, is a precius cmmdity, and we request yur curtesy and cncern. If yu need t pstpne r cancel yur surgery mre than 2 (tw) weeks befre surgery, yu are entitled t a full refund unless the depsit was made with a credit card. If s 10% f the depsit will be withheld t cver credit card fees. If less than 2 (tw) weeks' ntice is given fr pstpnement r cancellatin the depsit f $300 will be held as an administratin fee. Shuld yu find it necessary t pstpne r cancel 5 (five) days r less befre surgery we will refund yur payment except fr 25% f the ttal cst f yur peratin. This will be cnsidered a nn-refundable cancellatin fee. If yu d nt shw up fr yur surgery date r decide t pstpne r cancel the surgery with less than 48 hurs ntice, 75% f the ttal cst f yur peratin will be cnsidered a nn-refundable cancellatin fee. Patient Signature: Date: