Liposuction Surgical Consent and Treatment Contract

 

I have read Important Information about Tumescent Liposuction.  I have had all my questions answered.  I understand the risks and the possible range of outcomes.

I have read the Preoperative Instructions and intend to follow them.  I agree not to drive for 24 hours after surgery and will read the postoperative instructions.

I authorize Gordon Roget, M.D. and staff to perform liposuction of the following areas at the fees quoted. There is no charge for post-operative care up to and including the eight-week follow-up visit, or until four months postoperatively if there is an incision. 

If a repeat procedure is required or desired in the same area, I understand the fee will be 50% of the original charge if requested within six months of the original procedure and providing that there has not been more than a 10% increase in body weight.  Otherwise the full fee applies.  This is a “no-fault” contract with regards to repeat procedures.  I understand that I need to accept that cosmetic surgical outcomes vary and there is a chance of needing a repeat procedure that is not under the control of Dr. Roget.  Hence the charge for a repeat procedure is always as described above.  Outer thighs are most likely to need a repeat procedure; the chance is about one in seven.  No other area has more than a one in ten chance of needing a repeat procedure. 

I agree to allow Gordon Roget, M.D. and staff to photograph or video me before, during, and after the operation.  The photographs and videos shall be the property of Gordon Roget, M.D., and may be used for teaching, publication, scientific research, or explanation and promotion of liposuction procedures (including website “publication”).  Anonymity will be maintained, and the head and face will not be in the photos/videos except for facial liposuction, in which case the eyes and forehead will not be included.

I agree that I may be contacted at home or work regarding my surgery, and a message may be left for me at either home or work.

I know that liposuction should not be done if a woman is pregnant; I have no reason to suspect that I might be pregnant.  I understand that for abdominal liposuction, it is not known how well the abdomen will regain its shape after a future pregnancy. 

I understand that liposuction surgery may be postponed if I am ill and agree to contact Dr. Roget if I develop any illness or rash prior to surgery.

I agree to lab work, which may include HIV testing.  I have received counseling about HIV infection or do not desire any.  I understand that all charts are confidential and agree that the HIV result may be recorded in my chart.

Liposuction is associated with certain temporary side effects including soreness, bruising, swelling, inflammation, and minor irregularities of the skin.  Some of these effects can take several months to resolve.  An irregularity that persists for more than six months may or may not be correctable by a secondary procedure.  Any surgery involves risks of more serious and unexpected problems.  Although rare, examples of such complications include blood clots, excessive bleeding, scarring, infection, injury to other tissues, and allergic or toxic reactions to drugs.  In that tumescent liposuction is performed entirely under local anesthesia, a state-licensed operating room is not required, and is not provided by Dr. Roget.  Rare emergencies and complications could arise which could have been better managed in a licensed operating room.  Transfer to the hospital could be required.  I agree to be responsible for fees charged by other physicians or facilities. 

I acknowledge that no guarantee has been made as to the results of liposuction surgery.  I hereby request and give authorization for the above surgery or surgeries at the quoted fees. 

 

Patient signature                                                                                   Date