Breast Implant Removal Consent Form

Breast Implant Removal Consent Form

IMPORTANT INFORMATION: Please read and complete all sections of the consent forms electronically. Ensure a witness (a friend or family member is acceptable) is present to fill out their required sections clearly and legibly. Confirm that all fields, including the witness's details, are completed prior to submission.

I

FIRST NAME: *

LAST NAME: *

DATE OF BIRTH: *

consent to the procedure of breast implant removal (and medication or anaesthetic, if need be) being performed upon myself. Treatment area:

BilateralRightLeft

I fully understand the nature of the procedure. The possible complications have been fully explained to me, such as redness, swelling, lumps, peeling, scabbing, infection, scars, temporary or permanent pigmentation changes, pain, the need for further treatment, damage to other regions and other severe or unexpected side effects, such as death.

I am aware of the following possible complications of breast implant removal and consent to this procedure. I will not dispute what I have consented to including:

Infection

Scarring

Bleeding

Bruising

Hematomas

Seroma or fluid collections

Saggy breast that require a breast lift

Deformed shape of breast

Asymmetry

Retained capsule and the possibility of BIA-ALCL (lymphoma and possible death)

Clots in the legs and lungs and possible death

Damage to nerves, blood vessels, muscles and accessory structure

Anaesthetic complications

Depression and anxiety, plus other psychological disturbances

Loss of work, time or income

I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents of this form.

Pre- and post-operative photographs will be taken of the treatment site for record-keeping purposes. I understand that these photographs/videos will be the property of the Medical Director. Choose one: *

I DOI DO NOT

agree to allow these photographs to be used for publication or teaching purposes. If I agree I understand that my identity will be kept confidential and protected. Clinical photographs will be stored in a dedicated iPad.

Having discussed the reasonable expectations of my procedure with me, and having had all my questions answered to my satisfaction, I authorise Dr Glenn Murray and assistants of his choice, to perform this procedure and any other procedure(s) that in their judgement 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 understand that photographs will be used solely for clinical purposes unless I have explicitly given my consent by signing a separate photograph release form. I am responsible for taking my own photographs for my records.

INITIAL *

Agreement to treatment. INITIAL *

Patient/Substitute Decision Maker Full Name *

Patient/Substitute Decision Maker Signature *

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Date *

Witness Full Name *

Witness signature *

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Date *

I certify that I have discussed all the above with the patient and have answered all questions regarding the procedure. I believe that the patient fully understands what I have explained and answered.

Doctor's Full Name

Doctor's Signature

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Date signed

Dr. Glenn Murray

Registered Medical Practitioner (MED0001196978)

Medical Fellow of ACCSM - Australasian College of Cosmetic Surgery and Medicine.

Interpreter’s Declaration (if applicable)

Specific language services required

I declare that I have interpreted the dialogue between the patient/person(s) responsible and doctor/ healthcare provider to the best of my ability and have advised of any concerns about my interpreting of this dialogue.

Interpreter’s Full Name

Date

Interpreter’s Signature

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Agency name

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