Healthcare Face Lift Consent Form

HEALTHCARE FACE LIFT CONSENT FORM

Patient Information

Insurance Information

Medical History

Procedure Description

I, the undersigned, consent to the performance of a face lift procedure, which may include cervicofacial rhytidectomy, subcutaneous undermining, SMAS tightening, platysmaplasty, liposuction, and adjunctive procedures as deemed necessary by the surgeon. Procedure to be performed by: . Proposed procedure(s): . Scheduled date: .

Risks, Complications and Expected Outcomes

The patient acknowledges that the following risks, among others, may occur as a result of the face lift and associated procedures: infection, hematoma, seroma, unfavorable scarring, asymmetry, nerve injury (temporary or permanent), hair loss at incision lines, skin necrosis, persistent numbness, prolonged swelling, contour irregularities, poor wound healing, adverse reaction to anesthesia, thromboembolic events, and the potential need for revision surgery. The patient further acknowledges that no guarantees or promises have been made concerning the results.

Initial to indicate you understand major potential complications: Skin necrosis: Nerve injury: Hematoma/Seroma:

Alternatives and Non-Treatment

Alternatives to the recommended surgery include observation, non-surgical treatments (e.g., injectables, skin resurfacing, fillers), or different operative techniques. The patient understands that elective procedures may not fully correct the baseline condition and that non-surgical options may have limited benefit compared to operative correction.

Anesthesia and Blood Products

I consent to administration of anesthesia as deemed appropriate by the anesthesiologist. I understand anesthesia involves risks including allergic reactions and respiratory or cardiac complications. If blood transfusion is necessary, I consent to received/banked blood products unless I indicate otherwise below.

Photographs and Use of Images

I authorize clinical photography for medical records and treatment documentation. I understand that photographs may be used for educational, quality assurance, and professional review, with identifying information removed unless separate written authorization is provided. Consent for broader use (educational or promotional) must be obtained separately.

HIPAA / Privacy Acknowledgment

I acknowledge receipt of the practice's Notice of Privacy Practices and understand that my protected health information may be used or disclosed for treatment, payment, and healthcare operations unless restricted by law or specifically limited by written request. I authorize the release of my medical information as necessary to process claims and for continuity of care.

Authorization to Release Medical Records

I authorize the practice to release my medical records, operative reports, and photographs to other physicians, insurance companies, or authorized persons as needed for treatment and payment. This authorization expires on: .

Patient Consent Statement

By signing below I attest that I have read and fully understand the information on this form, that all my questions have been answered to my satisfaction, that the nature and purpose of the procedure, material risks, probable consequences and alternatives have been explained to me, and that I hereby give my voluntary consent to the performance of the above-described procedure and any additional procedures that, in the surgeon’s professional judgment, are necessary during the operation.

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