Healthcare Breast Augmentation Consent Form

Healthcare Breast Augmentation Consent Form

Patient Identification

Patient Name:

Date of Birth:   Gender:

Provider and Procedure

Proposed Procedure:

Planned Date of Surgery:

Description of Procedure, Alternatives and Expected Results

I understand that the procedure consists of augmentation of the breast(s) by means of implants and may include one or more of the following elements: implant pocket creation, implant insertion, adjustment of breast tissue, mastopexy (breast lift) if indicated, and dressing or drain placement. Reasonable anticipated benefits are improved breast size, contour, and symmetry. Alternative treatments include: no surgery, fat grafting, external prosthesis, staged surgery, or alternative reconstructive/revision procedures. No guarantee is made regarding final breast size, symmetry, scar appearance, or permanence of results.

Implant and Anesthesia Options

Implant Type (select all options discussed and chosen):

Silicone gel implant    Saline implant    Textured surface    Smooth surface

Placement and incision (as discussed):

Submuscular (under the muscle)    Subglandular (over the muscle)   

Incision site:

Anesthesia:

Risks, Complications and Material Facts

I have been informed, and understand, that risks of breast augmentation include but are not limited to: infection; bleeding or hematoma; seroma; poor wound healing and scarring; asymmetry; changes or loss of nipple and breast sensation (temporary or permanent); implant rupture or deflation; capsular contracture; rippling or palpability of implants; implant displacement or rotation; need for additional surgery including implant removal or revision; interference with mammography; inability to breastfeed or altered lactation; allergic reactions; adverse anesthesia reaction; deep vein thrombosis, pulmonary embolus, or death (rare). I acknowledge that implants are not lifetime devices and future surgery may be necessary.

Specific material facts acknowledged by patient:

Medical History and Current Health

Are you pregnant or trying to become pregnant? Yes    No

Consent for Photography and Medical Records

I authorize the taking of pre-operative, intra-operative, and post-operative photographs and videos for medical records, care planning, and educational use within the provider's practice. Identifying information will be protected in accordance with privacy practices.

I consent to clinical photography as described above.

Anesthesia and Blood Products

I consent to the administration of anesthesia as deemed necessary by the anesthesiologist or provider. I understand anesthesia risks include allergic reaction, heart or lung complications, stroke, and death (rare).

I consent to receive blood products if, in the judgment of the provider, they are necessary during or after the procedure.

Financial Responsibility and Medical Necessity

I understand that cosmetic procedures may not be covered by insurance. I accept financial responsibility for all fees associated with the procedure, including surgeon, anesthesia, facility, implants, and related care. If insurance is billed, I authorize release of medical information necessary for processing claims.

Acknowledgments and Patient Certification

I certify that I have had the opportunity to ask questions about the nature of the procedure, risks, benefits, and alternatives, and that my questions have been answered to my satisfaction. I understand that unforeseen conditions may require additional or different procedures than those described, and I authorize the surgeon to perform such procedures as necessary in the exercise of professional judgment.

I acknowledge that no guarantee or assurance has been made by anyone as to the results that may be obtained. I have informed the provider of all known medical conditions and medications. I understand I may withdraw my consent at any time prior to the procedure.

I acknowledge receipt of the practice's Notice of Privacy Practices and consent to the release of my protected health information for treatment, payment, and healthcare operations as necessary for this procedure.

Patient Questions and Preoperative Instructions

Consent Statement and Signature

By signing below I state that I have read and fully understand the foregoing and that the information I have provided is accurate and complete to the best of my knowledge. I voluntarily consent to the performance of the procedure(s), anesthesia, and any additional procedures as necessary for my health and safety. I have been given sufficient opportunity to discuss the procedure, risks, benefits, alternatives, and expected outcomes with my provider.

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