Patient Advisory & Consent Form

Please initial below indicating that you have read and agree with the following statements

1. Lipodissolve is an elective procedure to improve body contour and appearance. It will attempt to improve the problems of disproportionate or irregular localized accumulations of fat. Lipodissolve will have minimal to no effect on general obesity, excess or loose skin, or body contour irregularities, whether due to surface fat or to other structures.
2. I understand that my weight will be recorded throughout the series of Lipodissolve treatments. Although significant weight loss is not expected, weight gain will impede optimal results.

Common Reactions

1. Itching will begin immediately and continue for up to 2 hours after the procedure. You may take over-the- counter Benadryl tablets, which will cause drowsiness, or use ice to sooth the area.
2. Redness and warmth will begin anywhere from immediately, to hours after injection. The color of the skin and warmth may range from person to person but most often is similar to a sunburn; bright red and warmth that can be felt through clothing.
3. Tenderness of the area will begin after the lidocaine wears off and swelling begins, about 2-4 hours after the procedure. The most significant tenderness is within the first 48-72 hours, with most patients describing the areas as “really sore…like a strong work-out.” Most people are able to continue their daily activities, but we suggest planning to go home immediately after the procedure. It is also recommended that the patient not have any significant engagements for the first 72 hours after the treatment.
4. Swelling will begin a few hours after the completion of the treatment and will continue for days-weeks. The majority of the swelling will be gone in the first week, but residual swelling/healing can last for 6 weeks.
5. Nodules, which feel like hard raisins under the skin, are a very normal part of the healing process. These develop 1-2 weeks after treatment and usually resolve 6-8 weeks later.

Uncommon Risks/Complications (possible with any injectable procedures)

1. Infection
2. Fluid collections, including (seroma/hematoma)
3. Shock or allergic reaction requiring hospitalization
4. Discomfort (pain and sensitivity)
5. Lumps/irregularities (unpredictable)
6. Skin loss
7. Asymmetry, Permanent Pigmentation Changes

Pre and post-op photos will be taken of the treatment site for record purposes. I understand that these photos/videos will be the property of the attending physician.  I do____, do not ___ agree to allow these pictures to be used for publication, teaching purposes or the practice web site. If I agree, I understand that my name will be kept confidential and protected.

IF YOU HAVE ANY QUESTIONS, DO NOT HESITATE TO CALL THE OFFICE DURING BUSINESS HOURS AT (949) 888-9700, OR AFTER HOURS, CALL YOUR SURGEON, DR. BUNKIS CELL PHONE AT (949) 500-8856, OUR REGISTERED NURSE, TRACEY PRESCOTT AT (949) 338-6072, OR OUR PHYSICIAN’S ASSISTANT, STACY VENCILL AT (949)910-1609.

WITH AN EMERGENCY THAT REQUIRES IMMEDIATE ATTENTION, CALL 911 BUT PLEASE HAVE YOUR FAMILY NOTIFY DR. BUNKIS OF ANY PROBLEMS YOU MAY HAVE.

Having discussed the reasonable expectations of lipodissolve with me and having had all my questions answered to my satisfaction, I authorize and direct my practitioner to perform this procedure and any other procedure(s) that in their judgment may be necessary or advisable should unforeseen circumstances arise during the procedure. I understand that the practice of medicine is not an exact science and although good results are expected, there can be no guarantee as to the results. I certify that I have read and understood all of the above and that all the blank spaces were checked or filled in prior to my signature.

I, _________________________________________________certify that I have read and understand the “Lipodissolve” information sheets dated November 2008, that my health care provider has answered all of my questions to my satisfaction, and that I give my informed consent for this procedure.

Patient Signature________________________ Date__________________

Witness_______________________________ Date__________________

I certify that I or a member of my staff has discussed all of the above with the patient and have offered to answer any questions regarding the procedure. We believe that the patient fully understands the explanation and answers.

Practitioner Signature_____________________ Date_________________

Initial if copy requested/given to patient____________________________ Copy placed in chart __________________________________________

Copyright 11/87 Last revised 03/08
Stacy Vencill, PA and Juris Bunkis, M.D., F.A.C.S.