Operation Consent

INFORMED CONSENT FOR PLASTIC  SURGERY

IT IS A LEGAL REQUIREMENT THAT BEFORE ANY SURGICAL OPERATION THE PATIENT READS AND SIGNS A CONSENT FORM.  PLEASE DO NOT HESITATE TO ASK MR BOSE OR HIS NURSE ANY QUERIES ARISING FROM THIS FORM.

NAME:                                                

Date of Surgery:

Hospital Name: 

1. I HEREBY REQUEST AND AUTHORISE DR BOSE AIDED BY ANY ASSISTANTS HE MAY CHOOSE TO USE AND/OR REQUIRE TO PERFORM UPON MYSELF THE FOLLOWING OPERATION ON OR ABOUT THE ABOVE DATE OF SURGERY

IN MEDICAL TERMS, THE NAME OF THE PROCEDURE IS:-

 

 

 

2.  I HAVE CAREFULLY READ THE INFORMATION LEAFLET PERTINENT TO THE PROPOSED SURGERY AND I UNDERSTAND THIS INFORMATION.  FURTHERMORE, DR BOSE HAS FULLY EXPLAINED IN TERMS CLEAR TO ME, THE EFFECT AND NATURE OF THE OPERATION(S) TO BE PERFORMED, THE FORESEEABLE RISKS INVOLVED, ANY ALTERNATIVE METHODS OF TREATMENT, AS WELL AS WHAT I CAN EXPECT TO EXPERIENCE IF RECOVERY IS UNEVENTFUL.  MOST PATIENTS HAVE SURGERY WITH LITTLE DIFFICULTY BUT PROBLEMS CAN HAPPEN FROM MINOR TO EVEN FATAL.  LASTLY, I ACKNOWLEDGE THAT I HAVE BEEN GIVEN AN OPPORTUNITY TO ASK ANY QUESTIONS I DESIRE REGARDING THE MATTERS CONTAINED IN THE PRECEDING THREE SENTENCES AND THAT THESE QUESTIONS HAVE BEEN ANSWERED TO MY SATISFACTION.

3.  I ALSO AUTHORISE DR BOSE AND HIS ASSISTANTS TO PERFORM ANY OTHER PROCEDURES WHICH HE MAY DEEM NECESSARY OR DESIRABLE IN ATTEMPTING TO ACHIEVE THE OBJECT OF THE OPERATION(S) OR THE ELIMINATION OF ANY UNHEALTHY OR UNFORESEEN CONDITION THAT HE MAY ENCOUNTER DURING THE OPERATION(S).

4.  I CONSENT TO THE ADMINISTRATION OF ANAESTHETICS AND MEDICATIONS  TO BE APPLIED BY OR UNDER THE DIRECTION OF MR BOSE AND TO THE USE OF SUCH ANAESTHETICS AND MEDICATIONS AS HE MAY DEEM ADVISABLE IN MY CASE.   WITH  THE EXCEPTION OF:


To the best of my knowledge, I am only allergic to:

5.IT IS POSSIBLE THAT THE RESULT MIGHT NOT LIVE UP TO MY  EXPECTATIONS OR THE GOALS THAT HAVE BEEN ESTABLISHED.   I UNDERSTAND THAT THE PRACTICE OF MEDICINE AND SURGERY IS NOT AN EXACT SCIENCE AND THAT THEREFORE REPUTABLE PHYSICIANS CANNOT GUARANTEE RESULTS.  I ACKNOWLEDGE THAT NO GUARANTEE OR ASSURANCE HAS BEEN MADE BY ANYONE REGARDING THE OPERATION(S) WHICH I HAVE HEREIN REQUESTED AND AUTHORISED.

6.  I HAVE BEEN ADVISED THAT PART OF THIS SURGERY IS, OR MAY BE, PERFORMED THROUGH EXTERNAL EXCISIONS IN THE SKIN WHICH WILL LEAVE PERMANENT SCARS, WHOSE EXTENT AND LOCATION HAS BEEN DESCRIBED TO ME.  I HAVE BEEN ADVISED THAT SCARS TAKE UPWARDS OF ONE YEAR TO MATURE AND THE CHANGES THAT NORMALLY OCCUR IN THEIR APPEARANCE DURING THE HEALING PERIOD HAVE BEEN DESCRIBED TO ME.  THE LOCATIONS OF SCARS HAVE BEEN INDICATED TO ME BY  DR BOSE.

7.  I HEREBY GIVE PERMISSION TO DR BOSE OR ANY ASSISTANT HE MAY REQUIRE TO TAKE PHOTOGRAPHS FOR DIAGNOSTIC PURPOSES AND TO ENHANCE THE MEDICAL RECORD.  I AGREE THAT THESE PHOTOGRAPHS WILL REMAIN IN HIS POSSESSION.  I FURTHER AUTHORISE HIM TO USE SUCH PHOTOGRAPHS FOR TEACHING PURPOSES OR TO ILLUSTRATE SCIENTIFIC PAPERS, BOOKS OR LECTURES IF IN HIS JUDGEMENT MEDICAL RESEARCH, EDUCATION OR SCIENCE WILL BE BENEFITED BY THEIR USE.  IT IS SPECIFICALLY UNDERSTOOD THAT IN ANY SUCH PUBLICATION OR USE I SHALL NOT BE IDENTIFIED BY NAME.

8. I UNDERSTAND THAT IF DR BOSE JUDGES AT ANY TIME THAT MY SURGERY SHOULD BE POSTPONED OR CANCELLED FOR ANY REASON, HE MAY DO SO.

9.  I ALSO UNDERSTAND THAT I AM FREE TO WITHHOLD OR WITHDRAW MY  CONSENT AT ANY TIME BEFORE THE SURGERY WITHOUT EFFECTING MY RIGHT TO FUTURE CARE OR TREATMENT.

10. I AGREE TO FOLLOW THE INSTRUCTIONS GIVEN TO ME BY MR BOSE TO THE BEST OF MY ABILITY BEFORE, DURING AND AFTER THE ABOVE NAMED SURGICAL PROCEDURE.

11. I HEREBY STATE THAT THE INFORMATION I GAVE DURING MY DIAGNOSTIC EVALUATION IS CORRECT.

 

PATIENT’S  SIGNATURE

DATE                      TIME

 

WITNESS’ SIGNATURE (Not A Member Of Patient’s Family)

 

DATE                      TIME

 

I certify that all blanks in this form were filled in prior to above signatures and I explained them to he patient before asking the patient to sign.

 

SIGNATURE OF  PHYSICIAN                                     DATE                      TIME

Dr.Aniruddha Bose  

MBBS, FRCS, Diplomate NB, FICS, FISBI

Senior Consultant Plastic, Cosmetic & Reconstructive  Surgeon

 

 
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