CONSENT FOR BLEPHAROPLASTY

DARRYL J. HODGKINSON M.D. F.R.C.S.(C) F.A.C.S.

1. I hereby request the above named surgeon(s) and/or their associates to perform a surgical procedure known as blepharoplasty, a plastic surgical operation on the eyelids and surrounding structures. This procedure has been explained to me by the doctor(s) and I completely understand its nature and consequences.
2. I understand that every surgical procedure involves certain risks and possibilities of complications such as bleeding, infection, poor healing, etc and that these and other complications may follow even when the surgeon uses the utmost care, judgment and skill. These risks have been explained to me and I accept them. The following points have been explained in detail.

a. Incisions are used in and about the eyelids, and these incisions heal with scar tissue.
b. That there will be discolouration about the eyes for several days, and that in some cases this can persist for considerably longer.
c. Due to the nature of the procedure, an exact end result cannot be predicted and there is no guarantee of specific results.
d. That the incision lines usually are noticeable early post operatively and for an indefinite period of time.
e. It is not expected that vision would be interfered with but vision may be blurred for a few days due to swelling.
f. Ectropion or pulling down usually of the lower eyelids is an uncommon but possible complication that may require additional surgery for correction.
g. Cosmetics about the eyes are not to be used for at least one week after surgery.
h. The eyelids may have a more sunken appearance after surgery.
i. An extremely rare complication is blindness.

3. I have an understanding of the operation which includes but is not limited to the above items. I understand that secondary revisions may be required in some cases. I also understand that charges will be made for the use of the operating room, whether in the day surgery or in the hospital. I agree to be responsible for these charges.
4. I recognise that, during the course of the operation, unforeseen conditions may necessitate additional or different procedures than those outlined. I, therefore, further authorise and request that the above-named surgeon or his/her assistants perform such procedures as are, in his or her professional judgment, necessary and desirable. The authority granted under this Paragraph 4 shall extend to remedying condition that are not known to or could not reasonably be anticipated by the above doctor(s) at the time the operation is commenced.
5. I consent to the administration of local or general anaesthetic agents by or under the direction and supervision of the above doctor(s), anaesthetist, or nurse working with them.
6. I am aware 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 procedure; nor are there any guarantees against unfavourable results.
7. I consent to be photographed before, during and after the surgery; that these photographs shall be the property of the above doctors and may be used as they deem proper for scientific and educational purposes.
8. I agree to keep the above doctor(s) informed of any change of address, and I agree to cooperate with them in my care after surgery until completely discharged.
9. I understand that the doctors’ fees are separate from the anaesthesia and hospital charges, and implant costs and the doctors’ fees are agreeable to me. There may be a fee if a secondary procedure is required. Personal expectations vary; please ensure that you have liaised with your doctor and he has understood your expectations of surgery. Some operations require secondary or multiple procedures to obtain a better result.
10. Secondary surgical procedures are much more difficult than primary procedures. The operations for repair are much more complex than the primary operations because of scarring and more bleeding and bruising. The possibility of nerve damage and poor healing is greater and most importantly, the results are unpredictable. It is important for the patient to realise that the results of secondary surgery will never be as predictable as those of primary surgery. If a secondary procedure is necessary, further expenditure will be required, namely surgeon’s fees, the use of the operating room, anaesthesia and possibly hospitalisation. Before embarking on secondary surgery, you should be aware of your possible future commitments to multiple procedures in order to gain an acceptable result for yourself.
11. I have read a copy of the foregoing consent for the operation, understand it, accept these facts, and hereby authorise the above doctor(s) to perform this surgical procedure on me.

IF THE PATIENT IS A MINOR, COMPLETE THE FOLLOWING

The patient is a minor of ______ years of age; and we, the undersigned, are the parents or legal guardian of the patient and do hereby consent for the patient.

Parent or Legal Guardian ______________________________________________________________

Witness____________________________________________________________________________

20 Manning Road Double Bay N.S.W. 2028 Telephone: (02) 9362 7400 Facsimile: (02) 9328 6036