Liposuction Patient Advisory And Consent Form

Surgical Technique/Anesthesia/Facility/Recovery

1. Selection of anesthesia (local, local with IV sedation, epidural or general)
2. Selection of facility (outpatient surgical facility)
3. Dressings and supportive garments, including instructions for use
4. Possible need for post-op hospitalization
5. Restrictions and return to normal activities

Possible Temporary Complications: Possible Permanent Complications

1. Discoloration, swelling, permanent visible sars
2. Discomfort (pain and sensitivity)
3. Numbness Waviness-surface irregularities
4. Lumps/irregularities (unpredictable)
5. Asymmetry, Permanent Pigmentation Changes
6. Activity

Note: Fairly rapid resolution of most changes listed as temporary is expected, but final contouring may not be complete for six (6) months, occasionally longer.

Even though the risks and complications cited occur infrequently, these are the ones that are peculiar to the operation; other complications and risks can occur but are even more uncommon.

1. Patient does wish to have these described.
2. Patient does not wish to have these described.

Common Risks/Complications/Uncommon Risks/Complications

1. Shock requiring hospitalization and/or transfusion
2. Autologous blood transfusion
3. Contour irregularities/depressions
4. Persistent edema
5. Altered areas of sensation that could remain permanently
6. Fluid collections, including (seroma/hematoma)
7. Infection
8. Skin loss
9. Remote possibility of fat clots in the lung

Note: Must be off all aspirin-containing products and antiinflammatories for two (2) weeks before surgery and for two (2) weeks after surgery. Check all medications with physician.

Any and all of the Risks and Complications Can Results in

1. Hospitalization on occasion, surgical revisions (touch up) may be indicated.
2. Time off work.

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 (949-888-9700) OR AFTER HOURS, CALL YOUR SURGEON  - DR BUNKIS CELL PHONE NUMBER IS  (949) 500-8856, OR REGISTERED NURSE, TRACEY PRESCOTT’S NUMBER IS (949) 338-6072.  

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 liposuction with me and all my questions answered to my satisfaction, I authorize and direct my surgeon to perform this procedure and any other procedure(s) that in their judgment may be necessary or advisable should unforeseen circumstances arise during surgery. 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 “Liposuction” information sheets dated March 2008, that my surgeon 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.

Surgeon’s Signature_____________________ Date_________________

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

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