Informed Consent - Chin Augmentation Surgery (Page 5 of 5) in pdf

CONSENT FOR SURGERY / PROCEDURE OF TREATMENT

1. I hereby authorize Dr. Danny Oh, M.D. and such assistants as may be selected to

Perform the following procedure or treatment:

________________________________________________________________________

I have received the following information sheet:

INFORMED CONSENT for CHIN AUGMENTATION 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 know 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 has been given by anyone as to the results that may be

obtained.

5. I consent to the photographing or televising of the operation(s) or procedure(s) to be

Performed, including appropriate portions of my body, for medical, scientific or educational

purposes, provided my identity is not revealed by the pictures.

6. For purposes of advancing medical education, I consent to the admittance of observers to

The operating room.

7. I consent to the disposal of any tissue, medical devices or body parts that may be removed.

8. I authorize the release of my identity card number to appropriate agencies for legal

Reporting and medical-device registration, if applicable.

, IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:

a. THE ABOUVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN

b. THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF

TREATMENT

c. THERE ARE RISKS TO THE PROCEDURE OT TREATMENT PROPOSED

I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED

ITEMS (1-9).

I AM SATIFIED WITH THE EXPLANATION.

___________________________________________________________________________

Patient or person Authorized to Sign for Patient/Name

IC No

Date _________________________ Witness _____________________________________

Signature / Name

Informed Consent - Chin Augmentation Surgery Page 5