Pure Lipo Sculpt Center - Consolidated Patient Forms

1) Consultation Form
2) Informed Consent Lipolysis
3) Photography Authorization

4) Smoking Consent
5) Minor Procedure Patient Checklist
6) Post-Op Instructions

7) Informed Consent For Fat Transfer
8) Fees Cost and Cancellation

Instructions

This informed consent provides you with information concerning your suction-assisted laser lipolysis surgery and its risks.

General Information

Lipolysis is cosmetic surgery performed 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. Your doctor will sculpt and recontour your body by removing excess fat deposits that have been resistant to reduction by diet or exercise. Lipolysis may be performed as a primary procedure for body contouring or combined with other surgical procedures such as abdominoplasty, facelift, or thigh lift procedures to tighten loose skin and supporting structures.

The ideal candidates for lipolysis 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 this procedure. Skin that has diminished tone due to natural aging, stretch marks or weight loss will not reshape itself to the new contours and may require additional surgical techniques to remove and tighten excess skin.

Suction-assisted laser lipolysis surgery is performed by using a hollow metal surgical instrument known as a cannula carrying a laser delivery fiber that is inserted through small skin incision(s) and is passed back and forth through the area of fatty deposit as the laser is activated. The cannula attached to a vacuum source is then used to aspirate the fatty deposits. The procedure will use Nd:YAG laser with wavelength of 1064nm and/or 1319nm* depending on physicians preference. It may be performed under local or general anesthesia. After surgery, support garments and dressings are worn to control swelling and promote healing.

* 1064nm is cleared by FDA for laser lipolysis;

Treatment Alternatives

Treatment alternatives are not treating the fatty deposits, diet and exercise to reduce unwanted fat or other methods surgical removal of fatty deposits (including ultrasonic liposuction). Varying degree of risks and complications are associated with these treatment alternatives.

Risks Of Liposuction Surgery

Every medical procedure involves a certain amount of risk and every procedure has limitations. Your 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 your plastic surgeon to make sure you completely understand all possible consequences of lipolysis.

• Infection: Should an infection occur, additional treatment including antibiotics, hospitalization, or additional surgery may be necessary.
• Bleeding: If blood transfusion is needed to treat blood loss, there is a risk of blood-related infections.
• Patient Selection: Patients with poor medical health may not be candidates for liposuction.
• Scarring: All surgery leaves scars within the skin and deeper tissue. Some scars are more visible than others.
• Loss in Skin Sensation: Loss of skin sensation may occur which may or may not totally resolve.
• Skin Swelling/Discoloration: Bruising and swelling of skin near the surgical site normally occurs following liposuction.
• Irregular Skin Contour: Skin contour irregularities may occur after liposuction.
• Asymmetry: Additional surgery may be necessary to improve asymmetry.
• Seroma: Additional treatments to drain accumulations of fluid may be necessary.
• Surgical Anesthesia: There is risk of complications, injury, and even death from all forms of surgical anesthesia.
• Pain: Pain of varying intensity and duration may occur and persist after liposuction surgery.
• Skin Sensitivity: You may experience increased skin sensitivity after surgery.
• Deeper Structure Damages: The potential for this to occur varies according to the type of procedure being performed. Injury to deeper structures may be temporary or permanent.
• Healing Delay: Delayed wound healing and wound disruption can occur and may take longer to heal.
• Allergic Reactions: Adverse reactions may occur to drugs used during surgery and prescription medications after surgery.
• Fat Necrosis: Fatty tissue found deep in the skin might die and may produce areas of firmness within the skin which may require additional surgery to remove areas of fat necrosis.
• Pubic Distortion: Although rare, it is possible that women may to develop distortion of their labia and pubic area. Additional treatment including surgery may be necessary should this occur.
• Umbilicus Distortion: Change in appearance or loss of the umbilicus (navel) may occur.
• Persistent Swelling (Lymph edema): Persistent swelling in the legs can occur following liposuction.
• Surgical Shock: Individuals undergoing lipolysis where a large volume of fat is removed are at greater risk of complications. In rare circumstances, extensive lipolysis can cause severe trauma and even death can occur. Hospitalization and additional treatment would be necessary if surgical shock occurs after surgery.
• Deep Venous Thrombosis, Cardiac and Pulmonary Complications: Past history of blood clots, swollen legs or the use of estrogen or birth control pills that may increase your risk for these complications.
• Tumescent Anesthesia: There is the possibility that large volumes of fluid injected into the fatty tissue may result in systemic reaction to these medications.
• Laser-Assisted Lipolysis: Prolonged exposure of laser energy can produce excessive tissue damage (burn) which may require additional treatment and surgery. The long-term effect on tissue and organs to exposure to laser energy from the 1064nm and 1319nm wavelengths is unknown. It is possible that additional risk factors of laser-assisted lipolysis may be discovered in the future.
• Fat Transfer: Fat transfer can lead to swelling, bruising, & even infections similar to liposuction. Irregularities, overcorrection and under correction can occur as well.

Unsatisfactory Results

Although satisfactory results are expected, there is no guarantee expressed or implied, on the results that may be obtained. Risks pointed out above can occur. It may not be possible to improve the adverse effects of surgery.

Additional Advisories

Medications: Discuss with your surgeon any drug interactions that may exist with medications which you are already taking. Take your medication as directed by your surgeon. Long-Term Results: As you age, changes in body appearance will occur based on circumstances such as weight loss/gain, sun exposure, pregnancy and menopause that is not related to this surgery. Metabolic Status of Massive Weight Loss Patients: Individuals with metabolic abnormalities may be at risk for serious medical and surgical complications, including delayed wound healing, infection or even in rare cases, death. Female Patient Information: Inform your surgeon if you use birth control pills, estrogen replacement, or if you believe you may be pregnant. Many medications including antibiotics may neutralize the preventive effect of birth control pills, allowing for conception and pregnancy. Intimate Relations After Surgery: Refrain from sexual activity until your physician states it is safe. Mental Health Disorders and Elective Surgery: Prior to surgery, discuss emotional depression or mental health disorders with your surgeon. There may be psychological benefit from this surgery, but effects on mental health may not be accurately predicted. Smoking and Nicotine Products Exposure: Patients who smoke are at greater risk for complications of skin dying, delayed healing, additional scarring and negative effect on anesthesia and recovery from anesthesia. Please indicate your current status:
I do not use smoke and do not use nicotine products.
I am a smoker or use nicotine products. I understand the risk of surgical complications due to smoking and use of nicotine products.
Please refrain from smoking at least 4 weeks before surgery and until your physician states it is safe to return, if desired.

Additional Surgery Necessity

Medical practice is not an exact science. Additional surgery may become necessary if complications occur. Although satisfactory results are expected, there is no warranty expressed or implied, on the results that may be obtained.

Patient Compliance

Follow all physician instructions carefully. Restrict physical activity and avoid subjecting surgical site to excessive force during the healing period. Do not remove protective dressings and drains unless instructed by your physician. Not following up with physician for all follow up appointments will increase risk or complications.

Health Insurance

Most health insurance companies exclude coverage for surgical operations such as lipolysis or any complications that might occur from surgery. Contact your insurance company for a detailed explanation of their policies.

Financial Responsibilities

The cost of surgery 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. 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, you acknowledge that you have been informed about its risk and consequences and accept responsibility for the clinical decisions that were made along with the financial costs of all future treatments.

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. Your surgeon 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 below.

Consent For Lipolysis Consent Procedure Or Treatment

1. I hereby authorize   Dr. Denzel   and such assistants as may be selected to perform the following procedure or treatment:
   Laser Assisted Lipolysis with Aspiration.
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 acknowledge that no guarantee or representation has been given by anyone as to the results that may be obtained.
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 room.
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-device registration, if applicable.
10. I understand that the surgeons' 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:
    1. THE ABOVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN
    2. THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT
    3. 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

The use of photographs is essential to the planning and evaluation of cosmetic surgery. Your surgery will be photographically documented before, possibly during and after the procedure. These photographs are a permanent part of your medical record and will never be shown to anyone else without your consent.

For various reasons your doctor is often asked to show before and after photos of patients. Many patients, happy with their results, have given permission to use their photos anonymously. We now ask that you do so as well. I recognize that prospective patients, such as me, will ask to look at before and after photographs in the process of choosing a surgeon and evaluating specific procedures. I authorize the anonymous use of my photographs for this purpose by my doctor .

I understand that tobacco smoking increases health risks. My doctor and his staff have advised me to stop smoking. I will discontinue all smoking for six months before and six months after my surgery.

It has been explained to me that there is a decreased circulation secondary to smoking of tobacco and/or marijuana and that this can cause a delay in wound healing as well as skin breakdown, skin loss and scarring.

I agree to have a urine screening test for tobacco products during the preoperative period to confirm my compliance to a program of non-smoking. I also agree to the same urine screening tests during the postoperative period as my doctor deems necessary (i.e., wound or healing problems).

As a smoker, I understand that the surgery will have to be more conservative and less aggressive than usual to try to avoid these complications, which may still occur, despite the doctor's best efforts to avoid them.

This has been fully explained to me, and I relieve my doctor from any responsibility related to the increased risks from my smoking habits.
I am a non-smoker of tobacco. initial

I do not use social drugs. initial

Do not take aspirin, Advil, Motrin or Ibuprofen within two weeks prior to procedure date or one week after.

You should arrange transportation for after your procedure. Your ride may wait here for you or they can leave their contact information and we can call them when your procedure is close to being finished.

You should have eaten a full meal before you arrive for your procedure. The medications you will be taking can cause an upset stomach and vomiting if you take them on an empty stomach.

Wear loose and comfortable clothing for after your procedure.

You may shower with assistance later that same day if needed.

Remember... only walking activity for the first two weeks. We will advance your activity on a patient and recovery basis.

Please do not massage the areas until your doctor says it is ok to do so.

You may have been given a garment. Garments help with comfort, pain and swelling. You will wear it for up to two weeks. Some surgical areas and patients are not given garments for specific reasons. If you were not given a garment, please do not be alarmed. This decision is for your best recovery.

Please limit or discontinue your intake of the following items, one day prior to your procedure, to improve your recovery: salt, coffee, sugar, green tea and alcohol.

1. INCISIONS: Incisions can appear several different ways:
   • It may be closed with a small stitch which will be removed about one week after surgery.
   • It may have a drain inserted into the site and sutured into place (refer to DRAIN section).
   • It may be left open in order for the fluid to drain out on its own.
   One should expect a large volume of blood-tinged anesthetic solution to drain from the incision sites during the first 24 hours. This will vary from patient to patient. In general, the more drainage there is, the less bruising and the swelling there will be. You may have a few incisions drain for up to a week. Even though the fluid is red, it is only about 1% blood with the remainder being local anesthetic and saline. Maxi-pads are recommended for bandages over your drainage sites. These pads must be changed every 4-6 hours to prevent infection. Many patients have found it helpful to utilize a shower curtain or other protective pad on their mattress, underneath the sheets for the first several days after Body contouring procedures.
2. SHOWER: You may shower 24 hours after your surgery. If you have drains, put a long shoe lace or pantyhose around your neck and safety pin the drains to that.
3. MEDICATIONS: Post-op medications have been prescribed. Cephalexin (antibiotic) begin taking immediately following your surgery. Percocet or Vicodin/Hydrocodone should be taken as needed for pain. You may switch to Tylenol for pain control at your discretion. Do not combine Tylenol with Percocet or Vicodin. Phenergan can be taken if you experience nausea. Celebrex will help with inflammation. If you do experience nausea or vomiting it is probably from to the medication. Please try to take medication with food. If it persists, please contact our office. Lunesta or Ambien is a sleeping pill and may be taken at night for a full 8 hours sleep. You may experience a metallic taste in your mouth from Lunesta. DO NOT take any Ibuprofen based medications for 2 weeks prior or 1 week after your procedure.
   
   If you are unable to take any of these medications, please contact our office so we can arrange for other medications.
4. DIET: There are no dietary restrictions. Drink plenty of clear fluids. We recommend 8 glasses of water a day. We suggest you limit items that contain high levels of sodium such as soups. This will only increase your fluid retention.
5. COMMON SIDE EFFECTS:
   • A collection of fluid may develop under the skin and have a "waterbed" appearance. It may make you feel more uncomfortable and swollen. If this occurs, please call us. It is something we can easily address in the office.
   • If you have surgery on your lower extremities, you may experience additional swelling in your lower legs, calves and ankles. To minimize the swelling, keep your legs elevated as much as possible for the first 2 weeks.
   • Menstrual irregularities with premature or delayed onset of monthly menstruation are a common side effect of any significant surgery.
   • Flushing of the face, neck and upper chest may occur after liposuction and may last for a day or two.
   • Slight temperature elevation during the first 48 hours after surgery is a natural consequence of the body's reaction to surgical trauma.
   • Bruising varies between each patient. The more extensive the LipoSelection, the more bruising one can expect.
   • If you experience constipation it is probably due to the medication. Please try to increase your intake of prunes, fiber, and clear fluids. If it persists, please contact the office.
   • Males and females may experience significant swelling in the pubic region after lower abdominal liposuction. Males may need to purchase an Athletic Support Garment for significant genital swelling and elevation of the scrotum is recommended.
6. ACTIVITY: Rest for the first 24 hours. You may resume your normal activities as tolerated. If you experience more than mild swelling or discomfort you may be over doing it. This will not however affect the results of your surgery. During the first 1-2 weeks, walking is acceptable and encouraged. Once your doctor releases you, about 2-3 weeks after surgery, you can return to strenuous activities or aerobic exercise.
7. SORENESS: Post-operative discomfort usually takes the form of deep muscle soreness and usually improves over 2-7days. It is normal to have a pulling or pinching sensation for weeks and sometimes months following surgery. The surgical area may feel numb and you may start to feel lumps or bands of collagen. This is part of the healing process. Stretching is strongly advised and helpful. While stretching, you may feel a ripping sensation. This is normal and you should continue with the stretch and work through it.
8. MASSAGE: Therapeutic massage is very helpful to speed the healing process. Massage may be done as often as every day and as hard as you can tolerate beginning 1 week after surgery. Whirl-pools and hot tubs are permitted only after your incision sites have closed. This is usually at least one week after surgery.
9. EMOTIONAL RESPONSE: You may experience mild depression the first week after surgery. After this time your mood will improve after you see the swelling and bruising fade.
10. NO SMOKING!!!
11. EXPOSURE TO SUNLIGHT: Scars take at least one year to fade. During this time, you must protect them from the sun. Even through a bathing suit, a good deal of sunlight can reach the skin and cause damage. Wear sunscreen with a SPF of at least 15 at all times when in the sunshine. Be extremely careful if you have areas of reduced sensitivity. The same rules apply for tanning beds.
12. ICE & HEAT: Be careful when applying ice or heat to the surgical areas. You have a decreased perception of cold and hot to the treated areas. Even using a heated car seat could potentially cause a burn.
13. GARMENT: You may or may not be given a garment to wear after your surgery. If you are given one, wear it at all times (except when bathing) until your doctor advices otherwise. Please have someone assist you when taking it on and off for the first couple of days because you may become lightheaded. If the neck area was treated and you were given a garment, you must wear it 24 hours a day for 3-4 days. DO NOT REMOVE IT FOR ANY REASON. Continue to wear it as much as possible for an additional 4-7 days as directed by the physician. Supplies to have on hand:
    • Shower curtains to be placed over your car seat and mattress
    • Maxi pads to place directly on wound site
    • Wet-Ones to clean up bathroom
    • Old set of sheets & blankets
    • Bed pad or chux
    FYI: Prepare car seat, bed and pathway to restroom to protect areas from drainage.
    
    PLEASE REMEMBER THAT FOR THE MAJORITY OF PATIENTS THE GOAL IS SIGNIFICANT IMPROVEMENT, NOT PERFECTION.

Instructions

This is an informed-consent document that has been prepared to help inform you concerning fat transfer (fat grafts or fat injection procedures), its risks, and alternative treatments.

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 the procedure or surgery as proposed by your plastic surgeon.

Introduction

A person's own fat may be used to improve the appearance of the body by moving it from an area where it is less needed (usually the thights or abdomen) to an area that has lost tissue volume due to aging, trauma, surgery, birth defects, or other causes. Typically, the transferred fat results in an increase in volume of the body site being treated. Before the procedure, the areas from where the fat is being removed may be injected with a fluid to minimized bruising and discomfort. The fat may be removed from the body by a narrow surgical instrument (cannula) through a small incision or may be excised (cut out) directly through a larger incision. In some cases the fat may be prepared in a specific way before being replaced back in the body. This preparation may include washing, filtering, and centrifugation (spinning) of the fat. The fat is then placed into the desired area using either a smaller cannula or needle, or it may be placed directly through an incision. Since some of the fat that is transferred does not maintain its volume over time, your surgeon may inject more than is needed at the time to achieve the desired end result. Over a few weeks, the amount of transferred fat will decrease. At times, more fat may need to be transferred to maintain the desired results. Fat transfer procedures may be done using a local anesthetic, sedation, or general anesthesia depending on the extent of the procedure.

Alternative Treatments

Alternative forms of nonsurgical and surgical management consist of injections of man-made substances to improve tissue volume (such as hyanuronic acid, polylactic acid, etc.), use of man-made implants, or other surgical procedures that transfer fat from the body (flaps). Risks and potential complications are associated with alternative forms of treatment.

Risks Of Fat Transfer Procedures

Every procedure involves a certain amount of risk, and it is important that you understand the risks involved. An individual's choice to undergo a procedure is based on the comparison of the risk to its potential benefit. Although the majority of patients do not experience these complications, you should discuss each of them with your plastic surgeon to make sure you understand the risks, potential complications, and consequences of the procedure.

• Bleeding: It is possible, though unusual, to experience a bleeding episode during or after this procedure. Should bleeding occur, it may require emergency treatment to drain accumulated blood (hematoma). Do not take any blood thining medications, aspirin, or nonsteroidal anti-inflammatory medications (acetaminophen is acceptable) for ten days before the procedure, as these may contribute to a greater risk of bleeding or significant bruising. Tell your surgeon if you are on any of these medications before stopping them.
• Seroma: Although unlikely, a collection of fluid may appear at the site where the fat was removed. This is usually treated by draining the fluid with a needle.
• Infection: Infection is unusual after this procedure. Should an infection occur, additional treatment including antibiotics or surgery may be necessary.
• Scarring: All invasive procedures leave scars, some more visible than others. Although good wound healing after a procedure is expected, abnormal scars may occur both within the skin and in the deeper tissues. Scars may be unattractive and of different color than the surrounding skin. There is the possibility of visible marks from sutures used to close the wound. Scars may also limit motion and function. Additional treatments including surgery may be needed to treat scarring.
• Change in Appearence: Typically the transferred fat loses some of its volume over time and then becomes stable. It is possible that more treatments may be needed to maintain the desired volume of the transferred fat and resulting appearance. Less commonly, if you experience significant weight gain, the transferred fat may increase in volume and cause an undesirable appearance. It is important to understand that more than one treatment may be needed and therefore to discuss with your surgeon the costs associated of repeat treatments.
• Firmness and Lumpiness: While most transferred fat results in a natural feel, it is possible that some or all of the fat may become firm, hard, or lumpy. If some of the fat does not survive the transfer, it may result in fat necrosis (death of transferred fat tissue), causing firmess and discomfort or pain. Cysts may also form at the site of the transferred fat. Surgery may be required to improve such conditions.
• Asymmetry: Symmetrical body appearance may not result from a fat transfer procedure. Factors such as skin tone, fatty deposits, bony prominence, and muscle tone may contribute to normal asymmetry in body features.
• Long term effects: Subsequent changes in the shape or appearance of the area where the fat was removed or placed may occur as the result of aging, weight loss or gain, or other circumstances not related to the fat transfer procedure.
• Pain: Chronic pain may occur rarely after fat removal or transfer.
• Tissue Loss: In rare cases, the transferred fat may cause the skin over the treated area to be injured resulting in loss of the skin and surrounding tissue. This may leave scars and disfigurement and require surgery for treatment.
• Fat Transfer to Breasts: Fat transfer has been used to improve the appearance of breasts reconstructed after cancer treatment, to improve the appearance of breast deformities, and to enlarge breasts for cosmetic purposes. While there is limited information regarding the long-term implications of such procedures, there are some potential concerns especially with regards to breast cancer detection. Since the transferred fat may become firm and cause lumps, it may be necessary to have radiological studies (mammogram, ultrasound, or MRI) performed to be sure these lumps are not due to cancer. It is also possible that the firmness may make it more difficult for you or your doctor to examine the breasts. It is also possible that a biopsy may be needed if there is concern about any abnormal findings in your breasts. However, there is no reason to believe that fat transfer procedures may cause breast cancer.
• Damage to deeper structures: Deeper structures such as nerves, blood vessels, or muscles may be damaged during the course of this procedure. The potential for this to occur varies according to where on the body the procedure is being performed. Injury to deeper structures may be temporary or permanent.
• Unsatisfactory result: There is the possibility of an unsatisfactory result from the procedure, resulting in unacceptable visible deformities, loss of function, wound disruption, skin death, or loss of sensation. You may be disappointed with the results of the procedure.
• Allergic reactions: In rare cases, local allergies to tape, suture material, or topical preparations have been reported. Systemic reactions, which are more serious, may result from drugs used during the procedure or prescription medicines. Allergic reactions may require additional treatment.
• 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.
• Serious Complications: Although serious complications have been reported to be associated with fat transfer procedures, these are very rare. Such conditions include, but are not limited to: Fat embolism (a piece of fat may find its way into the blood stream and result in a serious or life threatening condition), stroke, meningitis (inflammation of the brain), serious infection, blindness or loss of vision, or death.
• Blood clots: Blood clots in the veins of the arms, legs, or pelvis may result from from fat transfer if it is done as a surgical procedure. These clots may cause problems with the veins or may break off and flow to the lungs where they may cause serious breathing problems.
• Pulmonary complications: Pulmonary (lung and breathing) complications may occur from both blood clots (pulmonary emboli) and partial collapse of the lungs after general anesthesia. Should either of these complications occur, you may require hospitalization and additional treatment. Pulmonary emboli can be life-threatening or fatal in some circumstances. Fat embolism syndrome occurs when fat droplets are trapped in the lungs. This is a very rare and possibly fatal complication of fat transfer procedures.

Additional Surgery Necessary

In some situations, it may not be possible to achieve optimal results with a single procedure. Multiple procedures may be necessary. Should complications occur, surgery or other treatments may be necessary. Even though risks and complications occur infrequently, the risks cited above are the ones that are particularly associated with fat transfer procedures. 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 cannot be any guarantee or warranty expressed or implied on the results that may be obtained.

Financial Responsibilities

The cost of the procedure involves several charges for the services provided. The total includes fees charged by your doctor, the cost of surgical supplies, laboratory tests, and possible hospital charges, depending on where the surgery is performed. Depending on whether the cost of the procedure is covered by an insurance plan, you will be responsible for necessary co-payments, deductibles, and charges not covered. Additional costs may occur should complications develop from the procedure. Secondary surgery or hospital day-surgery charges involved with revisionary surgery would also be your responsibility.

Disclaimer

Informed-consent documents are used to communicate information about the proposed treatment of a disease or condition along with disclosure of risks and alternative forms of treatment(s). 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. Your plastic surgeon may provide you with additional or different information that is based on all the facts in your particular case and the 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 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.

Consent For Surgery, Procedure or Treatment

1. I hereby authorize Dr. Denzel and such assistants as may be selected to perform the following procedure or treatment:
   Fat transfer including fat injections and fat grafts
2. I have received the following information sheet:
   INFORMED-CONSENT FAT TRANSFER PROCEDURES
3. 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.
4. 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.
5. I acknowledge that no guarantee has been given by anyone as to the results that may be obtained.
6. I consent to the photographing or televising of 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.
7. For purposes of advancing medical education, I consent to the admittance of observers to the operating room.
8. I consent to the disposal of any tissue, medical devices or body parts which may be removed.
9. I authorize the release of my Social Security number to appropriate agencies for legal reporting and medical-device registration, if applicable.
10. IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
    1. THE ABOVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN
       
    2. THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT
       
    3. 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.

Financial Policies

As patients approach surgery, they inquire about the various payment options. We hope the following information will be helpful. Our patient coordinators are readily available to meet with you personally to provide the specific information you desire.

Consultations/Post Op Visits

A consultation is free of charge with Dr. Denzel. There is also no charge for any post op visits.

How to Secure a Surgical Date

A deposit of $300 is required to book your surgery. This amount will be deducted from the remainder of the fees, which is due and payable two weeks prior to your surgery date, usually at your preoperative appointment.

Credit Cards

Visa, MasterCard, Discover or American Express are all acceptable forms of payment.

Cash or Check

Cashier's check, money order, bank cash or debit card is all acceptable forms of payment. Personal checks are acceptable only if they are certified.

Cancellation Policy

We understand that a situation may arise that could force you to postpone your surgery. Please understand that such changes affect not only your doctor but other patients as well. Dr. Denzel's time, as well as that of the procedure room staff, is a precious commodity, and we request your courtesy and concern.

If you need to postpone or cancel your surgery more than 2 (two) weeks before surgery, you are entitled to a full refund unless the deposit was made with a credit card. If so 10% of the deposit will be withheld to cover credit card fees. If less than 2 (two) weeks' notice is given for postponement or cancellation the deposit of $300 will be held as an administration fee.

Should you find it necessary to postpone or cancel 5 (five) days or less before surgery we will refund your payment except for 25% of the total cost of your operation. This will be considered a non-refundable cancellation fee.

If you do not show up for your surgery date or decide to postpone or cancel the surgery with less than 48 hours notice, 75% of the total cost of your operation will be considered a non-refundable cancellation fee.

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