AESTHETIC SURGERY
Narva Kliinik OÜ
Aasa 4 Narva
Office phone: 3929929
Cell phone: 5066907
REQUEST FOR SURGICAL SERVICES AND INFORMED CONSENT
To the patient: You have the right to be informed about your condition and its treatment so you may make
the decision whether or not to undergo the procedure after knowing the risks and hazards involved. This
disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you
may give or withhold your consent for treatment.
I voluntarily request my physician, Dr.___________________________________________________ ,
and such associates, technical assistants and other health care providers he/she may deem necessary, to
treat my condition. The procedure has been explained to me as:
___________________________________________________________________________________
I understand that my physician can discover other conditions, which require additional or different
procedures than those planned. I authorize my physician, and such associates, technical assistants, and
other health care providers to perform other procedures that are advisable in their professional judgment.
Initial if you understand and agree
I understand that no warranty or guarantee has been made to me as to result or cure. Realistic expectations
are 50–75% improvement.
Some patients have great improvement and some have no appreciable improvement.
Initial if you understand and agree
Just as there are risks and hazards of continuing my present condition without treatment, there are also
risks and hazards to the performance of the surgical, medical and/or diagnostic procedures planned for
me. I realize that common to surgical, medical and/or diagnostic procedure is the potential for infection,
allergic reactions, bruising, bleeding, or hematoma formation. I also realize that the following risks and
hazards may occur in connection with the particular procedure:
(1) worsening or unsatisfactory appearance,
(2) creation of additional problems such as:
(A) poor healing or skin loss,
(B) nerve damage,
(C) painful or unattractive scarring, keloid formation or permanent skin pigment change or
(3) recurrence of the original condition.
Initial if you understand and agree
Dizziness may occur during the first week following surgery, particularly upon rising or lying or sitting
position. If this occurs, extreme caution must be exercised while standing. Someone must be present
when you shower during the early postoperative period. Do not attempt to walk if dizziness is present.
Initial if you understand and agree
I understand that secondary revisions or additional surgeries may be required in some cases. The cost of
any of these additional surgeries is one-half the original surgeon’s fee. I understand that I will also be
required to pay the additional anesthesia and operation room fees.
Initial if you understand and agree
I understand the risk involved in surgery and I am fully aware of the dangers of anesthesia. I accept such
risks and can fault neither the doctors and/or the anesthetist if an unfavorable circumstance should arise.
Initial if you understand and agree
I understand that the practice of medicine and surgery is not an exact science and I acknowledge that no
guarantees have been made to me as to the results of the operation or procedures nor are there any
guarantees against an unfavorable result.
Initial if you understand and agree
I have received a thorough explanation of my preoperative instructions. I understand these instructions
and have received copies for reference. I understand that should I have any questions about the
preoperative instructions I should not hesitate to call. I acknowledge my obligation to follow these
instructions closely and to visit the clinic for follow-up care and instructions on postoperatively.
Initial if you understand and agree
I certify that I have read the above consent and fully understand it. I have been given ample opportunity
for discussion and all my questions have been answered to my satisfaction. I have received no medication
before signing this consent. I hereby consent to surgery. This constitutes the full disclosure and
supersedes any previous verbal or written disclosures.
Initial if you understand and agree
NOTE: SINCE SMOKERS HAVE A HIGHER RATE OF RESPIRATORY COMPLICATIONS AND
DELAYEDWOUND HEALING, SMOKING IS NOT RECOMMENDED BEFORE OR AFTER
SURGERY.
Patient’s Pre-Surgery Signature Date and Time
Witness Signature