Appendix: Forms - Consent for Surgery

CONSENT FOR SURGERY: RHINOPLASTY and SEPTOPLASTY

Name and DOB:___________________________________

Diagnosis: _______________________________________

Procedure:________________________________________

I understand the nature of my condition and my diagnosis, I have been encouraged to ask questions, and my questions have been answered to my satisfaction.

Regarding any functional complaint, I understand the concept of maximal medical therapy, and that medical therapy - if it is effective - is preferable to surgery. I understand the wide range of medications available for treatment of my condition. For any functional complaint, maximal medical therapy has been tried and it has failed. I am unwilling to continue with further courses of medical therapy, as I feel they will be ineffective.

Dr. Becker and his office staff have provided me with information relating to my surgery and have reviewed it with me to my satisfaction. I understand the reasons for surgery and the goals of surgery. The object of the operation I have requested is improvement, not perfection. I understand there is a possibility that imperfections might ensue, and that the results might not live up to my expectations or the desired goals that have been established. In this connection, I know that the practice of medicine and surgery is not an exact science and that, therefore, a physician cannot guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the operation(s) that I have herein requested and authorized.

Dr. Becker has reviewed the surgical options with me, including the external ("open") and endonasal ("closed") approaches. I understand the option of no surgical treatment. I have decided to pursue surgical treatment for my condition.

I have been advised that any incisions made in the skin will leave a permanent scar. The extent and location of these scars have been described to me. I have also been advised that healing after surgery, including healing of any and all incisions, take up to one year for mature healing.

Copy to patient
Initials ____/____

I understand the specific risks of the proposed surgery. These include bleeding, infection, anesthetic risk, persistence or recurrence of the problem, septal perforation, unacceptable cosmetic result. Risks also include the need for further surgery with up to 1 in 10 or greater risk of the need for revision surgery. Some complications, such as skin injury, may not be correctible. I also understand the general risks of surgery, which include heart attack, seizures, stroke and death.

I agree to comply with the treatment plan, including followup visits, appropriate use of medications, some additional tests as needed, and monitoring of the outcome. I understand that additional treatment may be necessitated by a complication, or by a less-than-optimal outcome caused by circumstances that could not be foreseen or were not preventable.

Detailed information on this surgery has been provided, including the websites www.TheRhinoplastyCenter.com and www.RevisionRhinoplasty.com. I have also been provided with information from the medical literature on rhinoplasty. I have reviewed all of this information - especially the information on Risks and Complications related to the planned procedures - to my satisfaction and have asked questions to my satisfaction.

I understand that Dr. Becker's practice is located entirely in state of New Jersey. All of my medical and surgical care from Dr. Becker has taken place in the state of New Jersey.

_______________________
Name and date (PRINT)
_______________________
Signature and Date

_________________(physician)
___________________(witness)

copy to patient

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