Healthcare Fat Transfer Procedures

Healthcare Fat Transfer Procedures Consent and Authorization

Patient Name:    Date of Birth:    Medical Record #:

Patient Information

Female Male Other

Insurance Information

Medical History

Procedure Description

I authorize the physician and assistants to perform autologous fat transfer (fat grafting), which may include liposuction of donor sites, processing of adipose tissue, and injection of processed fat into the recipient site(s). Intended surgical site(s):

Estimated approximate volume to be transferred: . I understand that final volume transferred may change intraoperatively for safety and efficacy.

Risks, Complications, and Expected Outcomes

I acknowledge that no surgical procedure is without risk. Potential complications specific to fat transfer include, but are not limited to: infection; bleeding; bruising; scarring at donor or recipient sites; asymmetry; lumpiness or contour irregularities; fat necrosis and oil cyst formation; calcifications that may be detected on future imaging; partial or complete loss of transferred fat requiring repeat treatment; prolonged swelling; sensory changes; need for additional procedures to obtain or maintain desired result. Injection of fat into or near blood vessels carries a risk of fat embolism that can cause stroke, blindness, heart attack, or death, particularly with injections to the face or deep tissues. There may be unpredictable resorption of fat over time.

I understand that the physician cannot and does not guarantee a specific result, and that multiple procedures may be required to obtain or maintain the desired appearance. I have had the opportunity to ask questions regarding risks, benefits, and likely outcomes and those questions have been answered to my satisfaction.

Alternatives and Non-Surgical Options

Reasonable alternatives include non-surgical fillers, implants (if applicable), observation, topical or external contouring therapies, or no treatment. I understand alternatives, and I consent to proceed with fat transfer as described above.

Anesthesia and Perioperative Care

I consent to administration of anesthesia and sedation deemed appropriate by the anesthesiologist or surgeon. Options (select all that apply):

Local anesthesia Local with sedation/IV sedation General anesthesia

Use and Handling of Tissue & Photographs

I authorize use of harvested autologous tissue for the purpose of grafting to the indicated recipient site(s). I understand that excess tissue will be discarded according to facility policy unless otherwise documented. I consent to preoperative and postoperative clinical photography for treatment documentation and medical records. I understand photographs may be used for education or quality assurance with de-identification unless I expressly withhold consent below.

Consent to photography Do not use for non-clinical publication

HIPAA / Privacy Acknowledgment

I acknowledge that I have been provided or offered the clinic's Notice of Privacy Practices that describes how my protected health information may be used and disclosed. I authorize release of information necessary for billing and treatment. I consent to routine communication regarding appointments and treatment unless I indicate otherwise.

Consent and Patient Authorization

By signing below I certify that: I am the patient or the legally authorized representative of the patient; I am at least 18 years of age unless otherwise documented; I have read and understand this consent form; the nature, purpose, risks, benefits, and alternatives have been explained to me in terms I understand; I have had the opportunity to ask questions and all my questions have been answered to my satisfaction; I consent to the performance of the procedure(s) described and to any additional procedures that, in the physician's professional judgment, are necessary for my health or arising from the performance of the planned procedure(s).

Provider Attestation (for medical record)

I attest that I have explained the diagnosis, the nature and purpose of the proposed procedure(s), the risks and benefits, and the reasonable alternatives. I have answered the patient's questions and believe the patient understands the information provided.

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