INFORMED CONSENT FOR SURGICAL INTERVENTIONS

Buenos Aires , ...... 200.

Patient´s name:

1. I hereby authorize Dr ......and his surgical team to conduct the operation known as:

2. The mentioned intervention has totally been explained to me by the surgeon, and I understand the nature and consequences of this intervention.

The following items have been specially explained to me:

a) In the place of the incision it will always be left to a scar, having the necessary precautions to make it as unnoticeable as possible.

b) All smoker patients have an increased risk of suffering of the skin in the operated region.

c) The complications that can be originated by operations of plastic surgery are similar to those of any other type of operation and could be: inflammation, discoloration of the skin, hematoma, seromas, upheavals of sensitivity, abnormal scarring (queloide, hypertrophic, dehiscent healing, etc.), infection, necrosis, etc.

d) In interventions of bilateral structures, the symmetry cannot be guaranteed and can require later interventions for revision.

3. I am aware that during the course of the operation, unexpected conditions can need extra or different interventions than the pre-arranged, I therefore authorize and I require that the surgeon before named, or who he designates, makes the interventions that are necessary and desirable in his professional opinion including procedures like anatomo-pathological studies, x-rays, blood transfusions, etc. The granted authorization will extend to solve conditions unknown by the surgeon at the moment for beginning the operation.

4. I give my consent to the anesthesia administration under the direction of the surgeon or an anesthesiologist with the exception of..................................................... ..........

5. I am conscious that the practice of Medicine and Surgery are not an exact sciences and I recognize that the surgeon has informed to me suitably into the wished result of the operation. I accept that escapes to the possibilities of the surgeon to guarantee these results.

6. I give my consent to be photographed or to be filmed before, during and after the treatment being this material property of Xetica, being able the same being published in scientific magazines and/or exposed with educative medical purposes.

7. I authorize Dr .......or whom he designates, to make my follow-up and the necessary controls in the postoperative period.

8. I accept to cooperate with the postoperative cares indicated by the surgeon and his team, until having definitive the medical discharge.

9. I give faith of not have omitted or altered any data when exposing my clinical and surgical antecedents.

10. - I am allergic to ..................................................................................................

1. I have read at large this consent and I have totally understood it, authorizing Dr ........ to perform the mentioned surgery.

Name of Patient: ......................................

Passport nº: ........ ... .... .... ..

Signature: ..................................................................

Name of Accompanying Individual: ...............................

Passport nº: ....................................................

Signature: ...................................................................

Last Update : 18/03/2008