A Surgery is planned on …./…../……. in o2 Clinic (Ringlaan 51, 2600 Berchem, Belgium).
The procedures are sent to the patient in a proposal.
The surgery planned is the same as the proposal sent to the patient:
The operation will be in …………………….. anesthesia (choose: local, local with sedation, general anesthesia). I as a patient understand that in addition to the risks of surgery the anesthesia carries its own risk. Allergic reactions can occur to the local anesthetic. Local anesthesia with sedation is intended to make you more comfortable during the procedure and suppresses the consiousness. Although many people may have mild, temporary symptoms, general anesthesia itself is exceptionally safe. Rare complications, which may occur more frequently elderly patients, include: Temporary mental confusion, lung infections, stroke, heart attack, death. The risks and hazards have been explained to me, and I feel I have enough information to give this consent.I have been given an explanation of the proposed anesthesia plan, and have been given the chance to ask questions about it as well as other options. I’m informed that after a procedure with sedation or general anesthesia I cannot drive the car that day.
I, the patient, declare that I have been duly informed by Dr. Bart van de Ven concerning my operation and authorise him to perform the operation. In the interview I have had the opportunity to propose and resolve any doubts, and obtain all the complementary information I have felt necessary. Therefore, I consider myself able to weight the potential risks against the utility and benefits that the treatment can offer.
Potential complications of facial surgery include:
As a patient I realise that hoped results can not be guaranteed or claimed. A minimum of 6 months is needed for the skin tissues to recover from swelling and bruising. One year of healing is needed before an adequate evaluation of results can be made.
In some cases revision surgery may be needed. The surgeon’s fees would be waived in this case. The patient will in such case only be responsible for the following costs:
I understand all the content of this consent. I have no further questions and agree with this consent.
The relation between the patient and Dr Bart van de Ven is governed by the Belgian law. Any dispute arising will submitted be to the competent court of Antwerp.
I confirm I have been given at least 15 days reflection time since the initial consultation and proposal.
Present date: …./…../…….
Present place: Antwerp, Belgium.
Name Patient: ………………………..
Signature patient: …………………