VASER PRO LIPOSCULPTURE, SMOOTH AND/OR LIPOSCULPTURE 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.

 


ONLY SIGN IF YOU FULLY AGREE AND UNDERSTAND

Liposculpture - I fully understand the procedure

Realistic Expectations - results can vary

Possible outcomes - both short and long term

Lifestyle / Exercise / Diet - must be maintained

Fees from $2200.00 per area

Risks specific to the patient - inclusive of the possible impact of comorbities/patient history (can affect results)

Single or multiple procedures may be necessary as maximum removal is five (5) litres per procedure

Anaesthesia includes:

- Tumescent/local
- IV Sedation
- I understand the risks involved in the above

I understand the risks involved with incision sites and scarring

Antibiotics are commenced the day before the procedure

Oral analgesia will be provided post operatively.

Skin preparation Betadine (Iodine) - be aware of allergies

POST-OPERATIVE

Recovery times and specific care requirements

Compression garment to be worn:
- 3 weeks full time for 24 hours a day (i.e. day and night)
- Further 3 to 6 weeks continuously for 12 hours a day (i.e. day or night) 

- In some cases, patients choose to wear their garment full-time (24 hours) for 6 weeks in total 

Massage - only as instructed

Post-Operative exercises - as instructed

Regular follow-up appointments at day one, approximately 5-6 days and 1 month post operatively

Contact the clinic with any concerns at any time

Risks and Complications

Common:

Discolouration / bruising

Swelling / oedema

Minor irregularities

Restricted activity for two to three days (minimum)

Numbness for up to 12 months

Scarring

1 to 12 months for final result (50 - 90 % improvement)


Less Common:

Waviness / irregularities

Asymmetry (left ≠ right) 

Increased time off work

Infection

Pigmentation

Tattooing

Skin mottling

Lumpiness (lumps felt but not seen are common)


Rare:

Shock / blood loss

Revision Procedure/s or further treatment in both the short and long term (extra expense to the patient)

Need for hospitalisation (extra expense to patient)

Fluid collection:
- Seroma
- Hematoma

Skin necrosis (damage)

Reaction to anaesthesia

Perforations or adjacent structure injury

DVT, fat embolus and death

Surgical revision for loose skin

Other unexpected complications


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. 

Your procedure will be performed at Suite 1/21 Stirling HWY, Nedlands, WA, 6009.

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Consent needs to be signed at least 7 days prior to surgery.

A copy of the signed consent has been provided to me.

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

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Dr. Glenn Murray

Registered Medical Practitioner (MED0001196978) 

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



Interpreter’s Declaration (if applicable)

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.

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Sample Form V3 - March 2024