Mammary Implants Consent

INFORMED CONSENT FOR MAMMARY IMPLANTS

Buenos Aires , ........ , 200..

1. I hereby authorize Dr. ........and / or professionals designated by him, to include breast implants on my person (name and surname): ................................................................................ .................................................. ......

2. I have been widely informed of the nature and objectives of the intervention to be carried out on me, its risks, benefits and alternatives or options to achieve the desired results. I admit that I have not given assurances regarding the expected results of this intervention.

3. I have been explained that:
. At the site of the incision always will be a scar, despite taking all precautions to make it inconspicuous.
. The complications that can result from plastic surgery or other invasive procedures of the specialty are similar to those of any intervention of this nature, and can occur despite taking all necessary precautions to prevent them. They may consist of swelling, discoloration of the skin, bruising, asymmetries of volume and / or position of the implants, abnormal scar tissue, infection, disorders of the peripheral nerve conduction, necrosis, alterations of the vitality and / or sensitivity of areola or nipple, etc..
. Numerous literature reports that smoking has potential adverse effects on the results of operations of cosmetic surgery and may cause alterations in the normal healing and the vitality of tissues. For these reasons I have been recommended to reduce smoking for a period of ten days before and after the date of operation.
. In tandem with the general surgical risks, the breast implants involves certain risks including:
- Contraction of the capsule: the scar tissue that forms around the implant usually can tighten and compressing it. This can cause increased consistency, discomfort and, in some cases, external deformation requiring corrective surgery.
- Interference with standard mammography: the implant can interfere with standard mammography, which advises on all exploratory procedure of this kind, to inform the radiologist of the existence of implants.
- Explantation: implants can present some problems, which required their removal. The clinical or radiological suspect of breaking advocates the removal of the implant.
- The formation of a capsule around the breast prosthesis is normal and is due to the reaction of self-defense of the organism, it is usually asymptomatic and painless.
. There are studies that associate inclusions of silicone and other substances in the human body, with certain immune disorders or rheumatic (scleroderma, rheumatoid arthritis, lupus, etc..). A contrary view is held in other scientific papers updated, widely available internationally.
. I have been informed on the subject, I had the opportunity to ask questions on this matter and they were answered clearly.

4. I understand that during the course of the intervention, unforeseen conditions may arise that requires different procedures that those here referred. Therefore, I consent in the use of techniques and additional procedures or operations that may be required, including anatomic-pathologic studies, radiographic, blood transfusions, etc.

Likewise, I consent in the administration of anesthetic drugs, in the knowledge that they are not exempt from submitting certain risks that I have been clearly explained. In my case anesthesia will be administered by a specialist. Furthermore I am committed to cooperate with post op care to achieve the better result possible. I understand that I must bear the consequences of the abandonment of treatment on my part.

5. I express my consent to be photographed and / or filmed before, during and after treatment and that the material can be obtained exhibited for scientific or academic purposes, as far as my identity is not disclosed.

6. I declare under oath that I have not omitted or altered data of my clinical background.

7. I am allergic to: ........................................

8. I confirm that I have read and fully understand the terms of this agreement, that I had chance to ask questions, they have been satisfactorily answered and that all the blanks are filled in before my signature. I take responsibility for my choice to undergo surgery proposal.

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Patient Signature ID Number

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Witness Signature ID Number

Note: If the patient is under 21 years old, must sign a father and mother or guardian. If it is unable for reasons other than a lack of age, must sign its curator.

Signature father: