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Consent Risks Benefits Explained

Below are the consents that you should read multiple times before coming to your pre procedure appointment. They are very informative of all the risks and benefits that you will assume when having a rhinoplasty. Please reach out to us through our contact page if you need to have any questions answered. We would love to be of more help to you in any way!!

GENERAL INFORMED CONSENT FORM AND RELEASE AGREEMENT

Aesthetic Facial Plastic Surgery, PLLC’s ("AFPS"), by and through Dr. Philip Young, agree to provide treatment to: (“Patient” or “you”) pursuant to terms and conditions set forth under this General Informed Consent Form and Release Agreement (the “Agreement”) and such other consent or release AFPS may require from time to time.

Patient has received materials, literature and documents regarding AFPS’s policies and guidelines for pre- and post-procedure activities and prohibitions, as well as medications to avoid and release of rights, including but not limited to the following:

  1. Healing Body and Mind;
  2. Your Anesthesia Experience;
  3. Pre-Procedure Instructions;
  4. Medications to Avoid;
  5. Post-Procedure Instructions;
  6. Post-Operative Instructions for Your Specific Procedure that you are receiving;
  7. Patient Rights;
  8. Anesthesia Consent Form;
  9. Caretaker Consent Form;
  10. Pain Management Consent Form;
  11. Photographic / Videographic Documentation Consent Form

By executing this Agreement, Patient certifies that he/she has: (i) read; (2) understood; and (3) had an opportunity to ask questions regarding each section of this Agreement and all materials, literature and documents provided by AFPS. Patient understands that for each specific procedure, he/she will be required to sign additional consent forms addressing the specific risks, side effects, post-procedure care, etc., associated with those particular procedures Patient will undergo while under the care of AFPS. If the person signing as the “Patient” under this Agreement is doing so on behalf of a minor, then such person certifies that he or she is the parent, guardian, or conservator of the minor and that such person is authorized to sign this consent form on the minor’s behalf.

SECTION 1

INTRODUCTION TO AESTHETIC FACIAL PLASTIC SURGERY, PLLC

Aesthetic Facial Plastic Surgery, PLLC is a Professional Service Corporation which performs various plastic surgery procedures to enhance facial aesthetics of its patients. These procedures can help to reduce the visible signs of aging, but cannot stop the process of aging. Since each individual’s body is different, the risks and results of any medical procedure may vary from person to person. These procedures are generally performed under local, oral or conscious sedation and some individuals may need extra healing time and may not be able to return to work or normal activities for a prolonged period of time.

SECTION 2

ALTERNATIVES TO TREATMENT

There are surgical and nonsurgical methods for improving facial aesthetics and AFPS will provide you with options and alternatives that may be suitable for your objectives, which you should carefully review with your treating physician before deciding on one or more treatment procedures.

SECTION 3

RISKS OF PROCEDURES

Every medical and surgical procedure involves a certain amount of risk and it is important that you understand these risks. An individual’s choice to undergo a medical or surgical procedure is based on, among other things, the comparison of the risk to potential benefit. Although the majority of patients do not experience complications, you should discuss each of them with your physician to make sure you understand the potential risks, complications, and consequences of the associated procedures. Whenever the skin is cut or punctured, it heals with a scar. Some procedures will result in a permanent scar.

Normal symptoms that occur during the recovery periods: swelling and bruising, discomfort and some pain, crusting along the incision lines, numbness of operated upon skin lasting 3 months or possibly longer or permanent, itching, redness of scars.

With each individual procedure, the specific consent to perform the procedure will outline in more detail some of the symptoms, side effects and risks associated with such a procedure.

SECTION 4

POST-PROCEDURE CARE

Post-Procedure care is an important part of your plastic surgery experience. It is your obligation to make sure that you keep all your post-procedure appointments as directed and make sure that you promptly contact your physician and seek emergency care in case of a medical emergency. You must have a caretaker for the first 24 hours. You should also record how you are taking your medications. You should record the date and time of each prescription drug you are taking, how much and what medications are given, and the total amounts of the drugs that are left each and every time. Medications (especially pain medications) can be dangerous and you need to strictly follow the instructions on the prescription attached to the bottle.

SECTION 5

FINANCIAL POLICY REGARDING REVISION AND COMPLICATIONS

As you have been, or will be, advised, no plastic surgeon can guarantee a specific result. From time to time, some patients may require additional surgery to deal with revisions or complications. In cosmetic procedures, there are certain problems that are unavoidable regardless of quality of the care provided and diligence exercised by the doctor and his/her team.

Examples of problems that a patient may encounter include bleeding and/or an unfavorable scar after a surgical procedure. In both of these cases, the patient may require additional surgery, either on an emergency basis (as in the case with bleeding) or an elective basis (as in the case of scarring).

We hope that no complication arises and no revisionary surgery becomes necessary in your case. However, no plastic surgeon can make such a guarantee to any of his or her patients. It is important for the patient undergoing an elective surgical procedure to understand that surgical revisions and complications may result in additional costs. Revisions within six (6) months from the original procedure date will not incur additional physician fee; but facility, anesthesia and other fees and costs shall be the sole responsibility of the patient. Notwithstanding the foregoing, any revisions after six (6) months of the original procedure date will incur all standard fees and costs.

If you have any questions regarding this policy, our office staff would be happy to discuss it with you.

SECTION 6

DEPOSIT/FEE

A non-refundable fee in the amount of five hundred dollars ($500) will be collected at the time you schedule your surgery or C02 laser treatment. This fee will be applied towards the total costs of your surgery, which shall be collected in full at the time of your pre-op appointment (two weeks prior to your surgery date). If you choose to cancel your surgery for any reason before your pre-op appointment, then the $500 fee will remain non-refundable but may be applied to future surgery/procedure.

  1. If you decide to cancel or reschedule your surgery within two (2) weeks of your surgery date, you will be responsible to pay thirty percent (30%) of the total costs of the procedure.
  2. If you cancel or reschedule your surgery less than seven (7) days before the day of the procedure, you will be charged fifty percent (50%) of the total cost of the procedure.
  3. After your procedure, there are no refunds given.

For non-surgical treatments, including injectable or other laser treatments, all fees and costs must be paid in full on day of treatment. There will be a return check fee in the amount of thirty-five dollars ($35) for all returned checks. If you have any questions regarding our financial or refund policy, feel free to ask our Patient Care Coordinator or Office Manager.

SECTION 7

DISCLAIMERS, RELEASES AND COVENANTS

Computer imaging may be used during your consultation. Although we strive to achieve the very best results every time, these images are used to help guide us during your procedure and are not a guarantee of results.

You understand that AFPS will request or require you to sign the following consent forms:

  • Patient HIPAA Consent Form;
  • General Instruction Form;
  • Photographic/Videographic Documentation Consent Form;
  • Pain Management Agreement;
  • Caretaker Consent; and
  • Consent forms for each individual procedure you will undergo while under the care of AFPS.

Informed consent documents are used to communicate information about the proposed medical or surgical treatment along with disclosure of risks and alternative forms of treatment(s). The informed consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances. However, informed consent documents should not be considered all inclusive in defining other methods of care and risks encountered. Your physician may provide you with additional information, which is based on all the facts in your particular case and the state of medical knowledge. Informed consent documents are not intended to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all the facts involved in an individual case and are subject to change as science, knowledge, and technology advance and as practice patterns evolve.

For purposes of advancing medical education, you consent to the admittance of observers to the operating room.

  • You consent to the disposal of any tissue, medical device or body parts which may be removed.
  • You understand that the success of the procedure is to a great extent dependent upon your closely following Pre-Op and Post-Op instructions your doctor has provided to you. Post-Op care, activities and precautions have been explained to you and you understand them fully.
  • You also consent to the administration of such anesthetics as may be considered necessary and advisable by the attending physicians and/or anesthetist. You are aware that risks are involved with anesthesia, such as allergic or toxic reactions and even cardiac or respiratory arrest.
  • Your physician, and/or your physician’s designees, reserve the right to discuss your case with any third parties if, in your physician’s considered opinion, it becomes necessary to do so. Your signature below will indicate your consent to this reservation.
  • You have had sufficient opportunity to discuss your treatment with your physician and/or your physician’s associates, and all your questions have been answered to your satisfaction. You believe that you have adequate knowledge upon which to give an informed consent to the proposed treatment.
  • YOU ARE AWARE THAT THE PRACTICE OF MEDICINE IS NOT AN EXACT SCIENCE AND ACKNOWLEDGE THAT NO GUARANTEES OR PROMISES HAVE BEEN MADE TO YOU ABOUT THE RESULTS OF THE PROCEDURE OR CARE PROVIDED BY AFPS. YOU UNDERSTAND THAT THE RESULT OF YOUR PROCEDURE AND RECOVERY WILL VARY AND MAY NOT BE SIMILAR TO THE RESULTS AND RECOVERY OF THAT OF OTHER PATIENTS, INCLUDING THOSE DEPICTED IN AFPS ADVERTISING. WITHOUT FOREGOING YOUR RIGHT TO PURSUE REMEDIES AT LAW OR IN EQUITY AS A RESULT OF AFPS’S NEGLIGENCE OR MALPRACTICE AND IN CONSIDERATION OF AFPS’S AGREEMENT TO PROVIDE TREATMENT, YOU HEREBY COVENANT THAT YOU WILL NOT WRITE, COMPOSE, PUBLISH, DISSEMINATE, MAKE, OR OTHERWISE DIRECT OR ENCOURAGE ANY THIRD PARTY TO DO SO, ANY NEGATIVE REVIEWS OR DISPARAGING REMARKS AGAINST AFPS OR DR. PHILLIP YOUNG, IN ANY MEDIUM OR FORUM WHATSOEVER (COLLECTIVELY “DISPARAGING REMARKS”). IF YOU MAKE ANY DISPARAGING REMARKS, THEN YOU EXCLUSIVELY ASSIGN ALL INTELLECTUAL PROPERTY RIGHTS, INCLUDING COPYRIGHTS, TO AFPS FOR ANY SUCH DISPARAGING REMARKS INCLUDING BUT NOT LIMITED TO WRITTEN, PICTORIAL, AND/OR ELECTRONIC COMMENTARY. THIS ASSIGNMENT SHALL BE OPERATIVE AND EFFECTIVE AT THE TIME OF YOUR CREATION (PRIOR TO PUBLICATION OR DISSEMINATION) OF THE DISPARAGING REMARKS.

SECTION 8

MOTOR VEHICLE AND PROCEDURE DATE POLICY

You are advised not to operate a motorized vehicle or power equipment on the day of surgery. The drugs administrated during the procedure may impair driving ability and you should not drive when you are on any sedating medications such as sleeping pills, antihistamines, muscle relaxants, anti-anxiety medications, clonidine, and pain medications. AFPS recommends that you have someone drive you to and from our facility the day of your procedure, if you are taking pain or sedation medications.

You hereby release and hold AFPS and Dr. Phillip Young harmless from any and all actions, loss or injury sustained by you or any third party as a consequence of your operation of any motorized vehicle or equipment while under the influence of sedating medications prescribed to you.

SECTION 9

SMOKING

NO SMOKING FOR AT LEAST TWO (2) WEEKS BEFORE AND AFTER YOUR PROCEDURE!!! You have been informed by AFPS that you are not to smoke for at least two (2) weeks before and after your scheduled procedure at AFPS. If you are unable to maintain this nonsmoking policy before the procedure, then you must notify AFPS immediately to reschedule your procedure date. If you are unable to maintain the nonsmoking policy after your procedure, then you must notify AFPS and your doctor immediately to assess your health risk and seek appropriate medical attention as necessary. You understand that this policy is in place for your health and safety and you shall not hold AFPS and Dr. Phillip Young responsible for any negative result which may have been directly or indirectly caused by smoking.

You hereby attest that you have read and understood the above information carefully and have had all your questions answered before signing the consent form.

SECTION 10

ADVANCED MEDICAL DIRECTIVE

You acknowledge that you have been informed that your Advanced Medical Directive will be suspended while you are being treated at AFPS. You have given a copy of your Advanced Medical Directive document to the staff at AFPS; in the event that it is necessary that you be transferred to a hospital for acute care, every effort will be made to assure that a copy of this document will accompany you. You understand that it is not the responsibility of AFPS to advise each care provider (emergency responders, emergency room, acute care facility, etc.) of your Advanced Medical Directive and that you should keep a copy of your Advanced Medical Directive with you and your designated health care proxy should also maintain a copy of the form.

If no copy of the Advanced Medical Directive is supplied for your medical record, you release AFPS from any obligation or responsibility related to your status in this regard.

SECTION 11

CONSENT TO DRAW LABS FOR EXPOSURES

By signing this consent I also allow Aesthetic Facial Plastic Surgery and its Staff to carry out necessary blood work in the event of an accidental needle stick. The purpose of this is to allow Aesthetic Facial Plastic Surgery and its Staff to test your blood to see if you are a carrier of certain types of diseases including, but not limited to, Human Immunodeficiency Virus, Hepatitis, Syphillis, etc.

CONSENT FOR RHINOPLASTY

This is an informed consent document that has been prepared to assist your plastic surgeon inform you concerning Rhinoplasty surgery, its risks, and alternative treatment.

It is important that you read this information carefully and completely. Please initial each page, indicating that you have read the page and sign the consent for surgery as proposed by your plastic surgeon and agreed upon by you.

GENERAL INFORMATION

Surgery of the nose (Rhinoplasty) is an operation frequently performed by plastic surgeons. This surgical procedure can produce changes in the appearance, structure, and function of the nose. Rhinoplasty can reduce or increase the size of the nose, change the shape of the tip, narrow the width of the nostrils, or change the angle between the nose and the upper lip. This operation can help correct birth defects, nasal injuries, and help relieve some breathing problems.

There is not a universal type of Rhinoplasty surgery that will meet the needs of every patient. Rhinoplasty surgery is customized for each patient, depending on his or her needs. Incisions may be made within the nose or concealed in inconspicuous locations of the nose in the open Rhinoplasty procedure. In some situations, cartilage grafts, taken from within the nose or from other areas of the body may be recommended in order to help reshape the structure of the nose. Internal nasal surgery to improve nasal breathing can be performed at the time of the Rhinoplasty.

The best candidates for this type of surgery are individuals who are looking for improvement, not perfection, in the appearance of their nose. In addition to realistic expectations, good health and psychological stability are important qualities for a patient considering Rhinoplasty surgery. Rhinoplasty can be performed in conjunction with other surgeries.

ALTERNATIVE TREATMENT

Alternative forms of management consist of not undergoing the Rhinoplasty surgery. Certain internal nasal airway disorders may not require surgery on the exterior of the nose. Risks and potential complications are associated with alternative surgical forms of treatment.

RISKS OF RHINOPLASTY SURGERY

Every surgical procedure involves a certain amount of risk and it is important that you understand these risks and the possible complications associated with them. In addition, every procedure has limitations. An individual’s choice to undergo a surgical procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience the following complications, you should discuss each of them with your plastic surgeon to make sure you understand the risks, potential complications, and consequences of Rhinoplasty.

Bleeding- It is possible, though unusual, to experience a bleeding episode during or after surgery. Intraoperative blood transfusions may be required. Should post-operative bleeding occur, it may require an emergency treatment to drain the accumulated blood or blood transfusion. Hypertension (high blood pressure) that is not under good medical control may cause bleeding during or after surgery. Accumulations of blood under the skin may delay healing and cause scarring. Do not take any aspirin or anti-inflammatory medications for ten days before or after surgery, as this may increase the risk of bleeding. Non-prescription “herbs” and dietary supplements can increase the risk of surgical bleeding. Hematoma can occur at any time following injury. If blood transfusions are necessary to treat blood loss, there is the risk of blood-related infections such as hepatitis and HIV (AIDS). Heparin medications that are used to prevent blood clots in veins can produce bleeding and decreased blood platelets.

Infection- Infection is unusual after surgery. Should an infection occur, additional treatment including antibiotics, hospitalization, or additional surgery may be necessary.

Scarring- All surgery leaves scars, some more visible than others. Although good wound healing after a surgical procedure is expected, abnormal scars may occur within the skin and deeper tissues. Scars may be unattractive and of different color than the surrounding skin tone. Scar appearance may also vary within the same scar. Scars may be asymmetrical. There is the possibility of visible marks in the skin from sutures. In some cases scars may require surgical revision or treatment.

Damage to Deeper Structures- There is the potential for injury to deeper structures including nerves, tear ducts, blood vessels, muscles, and lungs (pneumothorax) during any surgical procedure. The potential for this to occur varies according to the type of Rhinoplasty procedure being performed. Injury to deeper structures may be temporary or permanent.

You can continue to read this more condensed continuation below...

Change in Skin Sensation- It is common to experience diminished (or loss) of skin sensation in areas that have had surgery. There is the potential for permanent numbness within the nasal skin after Rhinoplasty. The occurrence of this is not predictable. Diminished (or loss) of skin sensation in the nasal area may not totally resolve after Rhinoplasty. Asymmetry- The human face is normally asymmetrical. There can be a variation from one side to the other in the results obtained from Rhinoplasty. Additional surgery may be necessary to attempt to revise asymmetry. Skin Discoloration / Swelling- Some bruising and swelling normally occurs following Rhinoplasty. The skin in or near the surgical site can appear either lighter or darker than surrounding skin. Although uncommon, swelling and skin discoloration may persist for long periods of time and, in rare situations, may be permanent. Seroma- Fluid accumulations infrequently occur in between the skin and the underlying tissues. Should this problem occur, it may require additional procedures for drainage of fluid. Pain- You will experience pain after your surgery. Pain of varying intensity and duration may occur and persist after Rhinoplasty. Chronic pain may occur very infrequently from nerves becoming trapped in scar tissue. Allergic Reactions- In rare cases, local allergies to tape, suture materials and glues, blood products, topical preparations or injected agents have been reported. Serious systemic reactions including shock (anaphylaxis) may occur to drugs used during surgery and prescription medications. Allergic reactions may require additional treatment. Delayed Healing- Fracture disruption or delayed wound healing is possible. Some areas of the nose may not heal normally and may take a long time to heal. Areas of skin may die. This may require frequent dressing changes or further surgery to remove the non-healed tissue. Smokers have a greater risk of skin loss and wound healing complications. Skin Sensitivity- Itching, tenderness, or exaggerated responses to hot or cold temperatures may occur after surgery. Usually this resolves during healing, but in rare situations it may be chronic. Nasal Septal Perforation- Infrequently, a hole in the nasal septum will develop. The occurrence of this is rare. Additional surgical treatment may be necessary to repair the nasal septum. In some cases, it may be impossible to correct this complication. Nasal Airway Alterations- Changes may occur after a Rhinoplasty or septoplasty operation that may interfere with normal passage of air through the nose. Surgical Anesthesia- Both local and general anesthesia involve risk. There is the possibility of complications, injury, and even death from all forms of surgical anesthesia or sedation. Substance Abuse Disorders- Individuals with substance abuse problems that involve the inhalation of vasoconstrictive drugs such as cocaine are at risk for major complications including poor healing and nasal septal perforation. Skin Contour Irregularities- Contour irregularities may occur. Residual skin irregularities at the ends of the incisions or “dog ears” are always a possibility and may require additional surgery. This may improve with time, or it can be surgically corrected. Sutures- Most surgical techniques use deep sutures. You may notice these sutures after your surgery. Sutures may spontaneously poke through the skin, become visible or produce irritation that requires removal. Unsatisfactory Result- Although good results are expected, there is no guarantee or warranty expressed or implied, on the results that may be obtained. You may be disappointed with the results of Rhinoplasty surgery. This would include risks such as asymmetry, loss of function, structural malposition, unacceptable visible or tactile deformities, unsatisfactory surgical scar location, poor healing, wound disruption, and loss of sensation. It may be necessary to perform additional surgery to attempt to improve your results. Shock- In rare circumstances, your surgical procedure can cause severe trauma, particularly when multiple or extensive procedures are performed. Although serious complications are infrequent, infections or excessive fluid loss can lead to severe illness and even death. If surgical shock occurs, hospitalization and additional treatment would be necessary. Cardiac and Pulmonary Complications- Surgery, especially longer procedures, may be associated with the formation of, or increase in, blood clots in the venous system. Pulmonary complications may occur secondarily to both blood clots (pulmonary emboli), fat deposits (fat emboli) or partial collapse of the lungs after general anesthesia. Pulmonary and fat emboli can be life-threatening or fatal in some circumstances. Air travel, inactivity and other conditions may increase the incidence of blood clots traveling to the lungs causing a major blood clot that may result in death. It is important to discuss with your physician any past history of blood clots or swollen legs that may contribute to this condition. Cardiac complications are a risk with any surgery and anesthesia, even in patients without symptoms. If you experience shortness of breath, chest pains, or unusual heart beats, seek medical attention immediately. Should any of these complications occur, you may require hospitalization and additional treatment. ADDITIONAL ADVISORIES Skin Disorders / Skin Cancer- Rhinoplasty is a surgical procedure to reshape of both internal and external structure of the nose. Skin disorders and skin cancer may occur independently of a Rhinoplasty. Long-Term Results- Subsequent alterations in nasal appearance may occur as the result of aging, weight loss or gain, sun exposure, pregnancy, menopause, or other circumstances not related to Rhinoplasty surgery. Future surgery or other treatments may be necessary. Female Patient Information- It is important to inform your plastic surgeon if you use birth control pills, estrogen replacement, or if you believe you may be pregnant. Many medications including antibiotics may neutralize the preventive effect of birth control pills, allowing for conception and pregnancy. Intimate Relations After Surgery- Surgery involves coagulating of blood vessels and increased activity of any kind may open these vessels leading to a bleed, or hematoma. Activity that increases your pulse or heart rate may cause additional bruising, swelling, and the need for return to surgery and control bleeding. It is wise to refrain from sexual activity until your physician states it is safe. Smoking, Second-Hand Smoke Exposure, Nicotine Products (Patch, Gum, Nasal Spray)- Patients who are currently smoking, use tobacco products, or nicotine products (patch, gum, or nasal spray) are at a greater risk for significant surgical complications of skin dying, delayed healing, and additional scarring. Individuals exposed to second-hand smoke are also at potential risk for similar complications attributable to nicotine exposure. Additionally, smoking may have a significant negative effect on anesthesia and recovery from anesthesia, with coughing and possibly increased bleeding. Individuals who are not exposed to tobacco smoke or nicotine-containing products have a significantly lower risk of this type of complication. Please indicate your current status regarding these items below: I am a non-smoker and do not use nicotine products. I understand the risk of second-hand smoke exposure causing surgical complications. I am a smoker or use tobacco / nicotine products. I understand the risk of surgical complications due to smoking or use of nicotine products. It is important to refrain from smoking at least 6 weeks before surgery and until your physician states it is safe to return, if desired. Mental Health Disorders and Elective Surgery- It is important that all patients seeking to undergo elective surgery have realistic expectations that focus on improvement rather than perfection. Complications or less than satisfactory results are sometimes unavoidable, may require additional surgery and often are stressful. Please openly discuss with your surgeon, prior to surgery, any history that you may have of significant emotional depression or mental health disorders. Although many individuals may benefit psychologically from the results of elective surgery, effects on mental health cannot be accurately predicted. Medications- There are many adverse reactions that occur as the result of taking over-the-counter, herbal, and/or prescription medications. Be sure to check with your physician about any drug interactions that may exist with medications which you are already taking. If you have an adverse reaction, stop the drugs immediately and call your plastic surgeon for further instructions. If the reaction is severe, go immediately to the nearest emergency room. When taking the prescribed pain medications after surgery, realize that they can affect your thought process and coordination. Do not drive, do not operate complex equipment, do not make any important decisions, and do not drink any alcohol while taking these medications. Be sure to take your prescribed medication only as directed. PATIENT COMPLIANCE Follow all physician instructions carefully; this is essential for the success of your outcome. It is important that the surgical incisions are not subjected to excessive force, swelling, abrasion, or motion during the time of healing. Personal and vocational activity needs to be restricted. Protective dressings and splints should not be removed unless instructed by your plastic surgeon. Successful post-operative function depends on both surgery and subsequent care. Physical activity that increases your pulse or heart rate may cause bruising, swelling, fluid accumulation and the need for return to surgery. It is wise to refrain from intimate physical activities after surgery until your physician states it is safe. It is important that you participate in follow-up care, return for aftercare, and promote your recovery after surgery. HEALTH INSURANCE Most health insurance companies exclude coverage for cosmetic surgical operations or any complications that might occur from cosmetic surgery. If the procedure corrects a breathing problem or marked deformity after a nasal fracture, a portion may be covered. Many insurance plans exclude coverage for secondary or revisionary surgery. Please carefully review your health insurance subscriber-information pamphlet. FINANCIAL RESPONSIBILITIES The cost of surgery involves several charges for the services provided. The total includes fees charged by your doctor, the cost of surgical supplies, anesthesia, laboratory tests, and possible outpatient hospital charges, depending on where the surgery is performed. Depending on whether the cost of surgery is covered by an insurance plan, you will be responsible for necessary co-payments, deductibles, and charges not covered. Additional costs may occur should complications develop from the surgery. Secondary surgery or hospital day surgery charges involved with revisionary surgery would also be your responsibility. ADDITIONAL SURGERY NECESSARY There are many variable conditions that may influence the long-term result from Rhinoplasty surgery. Secondary surgery may be necessary to obtain optimal results. Should complications occur, additional surgery or other treatments may be necessary. Even though risks and complications occur infrequently, the risks cited are particularly associated with Rhinoplasty surgery. Other complications and risks can occur but are even more uncommon. The practice of medicine and surgery is not an exact science. Although good results are expected, there is no guarantee or warranty expressed or implied, on the results that may be obtained. In some situations, it may not be possible to achieve optimal results with a single surgical procedure. DISCLAIMER Informed-consent documents are used to communicate information about the proposed surgical treatment of a disease or condition along with disclosure of risks and alternative forms of treatment(s), including no surgery. The informed-consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances. However, informed-consent documents should not be considered all inclusive in defining other methods of care and risks encountered. Your plastic surgeon may provide you with additional or different information which is based on all the facts in your particular case and the current state of medical knowledge. Informed-consent documents are not intended to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve. It is important that you read the above information carefully and have all of your questions answered before signing the consent on the next page. CONSENT FOR SURGERY / PROCEDURE or TREATMENT 1. I hereby authorize Aesthetic Facial Plastic Surgery and my doctor and such assistants as may be selected to perform the following procedure or treatment: RHINOPLASTY SURGERY I have received the following information sheet: INFORMED CONSENT - RHINOPLASTY SURGERY 2. I recognize that during the course of the operation and medical treatment or anesthesia, unforeseen conditions may necessitate different procedures than those above. I therefore authorize the above physician and assistants or designees to perform such other procedures that are in the exercise of his or her professional judgment necessary and desirable. The authority granted under this paragraph shall include all conditions that require treatment and are not known to my physician at the time the procedure is begun. 3. I consent to the administration of such anesthetics considered necessary or advisable. I understand that all forms of anesthesia involve risk and the possibility of complications, injury, and sometimes death. 4. I acknowledge that no guarantee or representation has been given by anyone as to the results that may be obtained. 5. For purposes of advancing medical education, I consent to the admittance of observers to the operating room. 6. I consent to the disposal of any tissue, medical devices or body parts which may be removed. 7. I consent to the utilization of blood products should they be deemed necessary by my surgeon and/or his/her appointees, and I am aware that there are potential significant risks to my health with their utilization. 8. I authorize the release of my Social Security number to appropriate agencies for legal reporting and medical-device registration, if applicable. 9. I understand that the surgeons’ fees are separate from the anesthesia and hospital charges, and the fees are agreeable to me. If a secondary procedure is necessary, further expenditure will be required. 10. I realize that not having the operation is an option. 11. IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND: a. THE ABOVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN b. THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT c. THERE ARE RISKS TO THE PROCEDURE OR TREATMENT PROPOSED I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED ITEMS (1-12). I AM SATISFIED WITH THE EXPLANATION. **Consent Will Be Signed Electronically as Part of the Medical Record** ANESTHESIA CONSENT FORM INSTRUCTIONS This is an informed consent document which has been prepared to help inform you about the anesthesia options available to you for your surgical procedure, their risks, as well as alternative treatment(s). GENERAL INFORMATION Washington State Law guarantees that you have both the right and the obligation to make decisions concerning your health care. Your physician can provide you with the necessary information and advice, but as a member of the health care team you must enter into the decision-making process. This form has been designed to acknowledge your acceptance of treatment recommended by your physician. TYPES OF ANESTHESIA OFFERED Please check the level of anesthesia you have chosen for your procedure, below: Local Sedation A local anesthetic agent such as Novocaine, Xylocaine, or Marcaine is introduced in to the tissue through injection and produces a numbness that allows surgery to be carried out with little to no discomfort while the patient is awake. Oral Sedation Local sedation is used in conjunction with Valium (sedative), Percocet (pain medication), and Phenergan (anti-nausea medication) which are ingested orally. You will experience little to no discomfort; be aware and conscious but fairly relaxed; and responsive to voice. Conscious Sedation with Registered Nurse and your Physician Versed or Fentanyl is administered through an intravenous line by our nurse. Other agents that are deemed necessary (with the patient’s safety and comfort as the utmost priority), may be used including, but not limited to, ketamine, propofol, robinul, lebatolol, flumazenil, naloxone, ondansetron, valium, dexamethasone, etc. This level is a little deeper state of sedation. You will be very sleepy but still responsive to more forceful amounts of voice and touch. Some refer to this type of sedation as Twilight. Conscious Sedation with a Certified Registered Nurse Anesthetist The last type of anesthesia offered is administered through an intravenous line given by a Certified Registered Nurse Anesthetist. This level can allow you to go into a deeper state of conscious sedation where you require more stimulation through touch and voice to become responsive. With this level of sedation, you will be much less aware of what is going on during the procedure than the other levels. RISKS OF ANESTHESIA I have been informed how each type of anesthesia is performed. I understand that all sedation and anesthesia medications involve risks of complications and serious possible damage to vital organs such as the brain, heart, lung, liver, and kidney, and that in some cases use of these medications may result in paralysis, cardiac arrest, and/or brain death from both known and unknown causes. I have been informed of possible alternative forms of treatment, including non-treatment. I understand that, during the course of anesthesia, operation, post-operative care, medical treatment, or other procedures, unforeseen conditions may necessitate additional or different procedures than set forth above. I therefore authorize my above-named physician, and his/her assistants or designees, to perform such procedures that are considered necessary and desirable, in their professional judgment. The authority granted under this paragraph shall extend to the treatment of all conditions that require treatment and are not known to my physician at the time the medical or surgical procedure is commenced. I consent to the administration of sedation or anesthesia by my attending physician, by an anesthesiologist, or other qualified party under the direction of a physician as may be deemed necessary. I hereby authorize my physician / Aesthetic Facial Plastic Surgery and/or such associates or assistants as may be selected by said physician to administer anesthesia. I certify that my physician has informed me of the nature and character of the proposed treatment, of the anticipated results of the proposed treatment, of the possible alternative forms of treatment, and of any recognized serious possible risks and complications of the proposed treatment and of alternative forms of treatment, including non-treatment. I CERTIFY THAT I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS, I HAVE HAD ALL ASPECTS OF THIS MEDICAL TREATMENT EXPLAINED TO MY SATISFACTION, AND I CONSENT. **Consent to be Signed Electronically as Part of the Medical Record** CARETAKER CONSENT FORM Your post-operative care is critical. Once you leave our office, your care will no longer be in our control and, therefore, you must have someone watching you carefully who can provide you the right doses of medicines. That is why our doctors recommend that you have 24 hour nursing care from a qualified nursing center. If instead you choose to have a family member or friend watch over you, then you must ensure that the person you select is qualified to take care of you during this critical state. Failure to have proper post-operative care may result in slowing your recovery, permanent damage and even death. Do not take the appointment of your caretaker lightly. We reserve the right to send you to an aftercare facility if we deem that your caretaker is not of sufficient status to care for you in the first 24 hours. FOR PATIENT TO SIGN I (full name) appoint (full name) as my post-operative caretaker for my surgery on (date). I understand that the doctors recommend that I have qualified 24 hour nursing care, but I choose this person as my caretaker and accept the risk of my decision. I also understand that my private medical information will be disclosed to my caretaker as needed to help with my recovery. I also understand that any failure on the part of my caretaker does not create a liability to AFPS, which is not responsible for my choice in caretaker and his/her abilities. I remain solely responsible for my decision. Patient Signature: Date: FOR CARETAKER TO SIGN I (full name) agree to care for during the post-operative period of 24 hours or more as necessary after surgery on _____ (date). I do not take this obligation lightly and understand that I could be liable for failure to care for the patient properly. I will keep patient’s medical information confidential and will not disclose said information to anyone except those people involved in patient’s care. I agree to monitor the patient’s vital signs by doing the following and keeping a record of my care: Staying in the same room as the patient; Making sure breathing is strong; Asking questions to make sure patient is able to respond; Making sure that the patient uses the restroom regularly; Giving liquids and food as directed; Giving the proper doses of medicine and recording patient’s response. All of these measures should be done on a regular basis over the course of the night. The intervals can be as frequent as every 5-15 minutes depending on the condition of the patient that you are caring for. If I have any question at all, I will call the doctor at 425 990 3223 or other numbers that are supplied to me. If there is any problem, I will immediately call 911 and the doctor at 425 990 3223 or other numbers that are supplied to me.. I also understand that signing this form does not create a relationship between myself and AFPS; instead, my sole relationship is with the patient, who has chosen me to be the caretaker. Any failure on my part does not make AFPS liable in any way. My phone numbers are: Caretaker signature: Date: PAIN MANAGEMENT AGREEMENT I understand that I have a right to comprehensive pain management along with the surgery that I will undergo. I wish to enter into a treatment agreement to prevent possible chemical dependency. I understand that failure to follow any of these agreed statements might result in Aesthetic Facial Plastic Surgery, PLLC (“AFPS”) and their physicians to not provide ongoing care for me. I agree to undergo pain management by Aesthetic Facial Plastic Surgery, PLLC. Pain Management provided by AFPS is for the purpose of post-operative plastic surgery. I agree to the following statements: I will not accept any narcotic prescriptions from another doctor unless approved by all physicians. I will be responsible for making sure that I do not run out of my medications on weekends and holidays, because abrupt discontinuation of these medications will cause severe withdrawal syndrome. I will only take the medication as directed by AFPS. I understand that I must keep my medications in a safe place. I understand that AFPS will not supply additional refills for the prescriptions of medications that I may lose. If my medications are stolen, AFPS will refill the prescription one time only if a copy of the police report of the theft is submitted to the physician's office. I will not give my prescriptions to anyone else. I will only use one pharmacy. I will keep my scheduled appointments with AFPS unless I give notice of cancellation 24 hours in advance. I understand that pain medications can affect my breathing and could lead to life threatening situations if I am not careful. I understand that I should not take too much medication that I am too tired or drowsy that will lead me to stop breathing and result in death. I understand that I have a maximum amount that I can take in a 24 hour period but that some people respond differently and this maximum may be less than what is stated and that I need to see how the medication is affecting me. I understand that if there is any question or concern regarding taking pain medications or taking too much pain medication then I will contact your Doctor immediately or call 911. I agree to refrain from all mind/mood altering/illicit/addicting drugs including alcohol unless authorized by AFPS. My treatment plan may change based on outcome of treatment, especially if pain medications are ineffective. Such medications will be discontinued. I understand that AFPS believes in the following "Pain Patients’ Bill of Rights." You have the right to: Have your pain prevented or controlled adequately. Have your pain and medication history taken. Have your pain questions answered. Know what medication, treatment or anesthesia will be given. Know the risks, benefits and side effects of treatment. Know what alternative pain treatments may be available. Ask for changes in treatments if your pain persists. Receive compassionate and sympathetic care. Receive pain medication on a timely basis. Refuse treatment without prejudice from your physician. Include your family in decision-making. Termination Clauses The doctor may terminate this agreement at any time if he/she has cause to believe that I am not complying with the terms of this agreement, or to believe that I have made a misrepresentation or false statement concerning my pain or my compliance with the terms of this agreement. Proof or verification of such beliefs is not required for termination and discontinuation of care. I understand that I may terminate this agreement at any time. If the agreement is terminated, I will not be a patient of AFPS or your particular physician and would strongly consider treatment for chemical dependency if clinically indicated. Date: Patient/Guardian Signature Print Patient/Guardian Name: Date: Physician Signature Print Physician Name: PHOTOGRAPHIC / VIDEOGRAPHIC DOCUMENTATION CONSENT FORM I hereby give my consent to the taking of photographs and/or video by Aesthetic Facial Plastic Surgery, PLLC ("AFPS") of me or parts of my body in connection with the procedure(s) to be performed by the physician at AFPS for the sole purpose of internal use at AFPS. I provide this authorization as a voluntary, yet private contribution: (i) for use in my medical files - patient chart - at AFPS; (ii) in the interests of the physician and office staff; (iii) for the purpose of facilitating consultations and procedural explanations to/for me; (iv) for AFPS training purposes. I understand that such photographs shall become the property of AFPS and may be retained by AFPS but will not be released by AFPS for any purposes such as print, visual or electronic media, medical journals and/or textbooks, or for the purpose of informing the medical profession or the general public about plastic surgery procedures and methods. I understand that I may be asked to sign a separate consent in the future for the purpose of releasing my photos for other uses such as advertising for the rights of AFPS, but will not be required to do so, and may refuse. I understand that I may refuse to authorize the release of my photos for internal use and that my refusal to consent to the release will not affect the health care services I presently receive, or will receive, from AFPS. I understand that I have the right to inspect and copy the information that I have authorized to be disclosed. I further understand that I have the right to revoke this authorization in writing at any time, but if I do so it will not have any effect on any actions taken prior to my revocation. I understand that the information disclosed, or some portion thereof, may be protected by state law and/or the federal Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). I release and discharge AFPS, the physicians, and all parties acting under the license and authority from all rights that I may have in the photographs and from any claim that I may have relating to such use in publication, including any claim for payment in connection with distribution or publications of the photographs. I certify that I have read the above Authorization and Release and fully understand its terms. If signing on behalf of a minor, I certify that I am the parent, guardian, or conservator of the minor and I am authorized to sign this consent form on the minor's behalf. **Consent Will Be Signed Electronically As Part of the Medical Record**