Healthcare Liposuction Consent Form

HEALTHCARE LIPOSUCTION CONSENT FORM

Patient Name:    Date of Birth:

Facility and Practitioner

Surgeon/Practitioner Name:

Procedure to be Performed

I authorize the surgeon to perform the following procedure(s):

Explanation of Procedure, Anesthesia, and Alternatives

The nature, purpose, and anticipated benefits of the proposed liposuction procedure and any associated fat grafting have been explained to me. The use of local, regional, conscious sedation, or general anesthesia (as indicated) has been explained, including attendant risks. I understand alternatives, including no treatment, non-surgical management, and alternative surgical approaches, have been discussed.

Risks, Complications and Potential Adverse Outcomes

I acknowledge that the following risks and complications have been explained to me. This list is not exhaustive:

• Bleeding, infection, need for antibiotics or additional surgery
• Contour irregularities, asymmetry, persistent swelling, shape deformity
• Scarring, hyperpigmentation or skin irregularities, skin laxity
• Numbness, changes in sensation, and possible permanent nerve injury
• Deep vein thrombosis, pulmonary embolism, cardiopulmonary complications, and rare death
• Seroma, hematoma, fat necrosis, fat embolism (rare but serious)
• Unfavorable aesthetic result or need for revision surgery
• Possible organ or internal structure injury from instrument penetration (rare)

I understand there is no guarantee of specific results and that additional procedures may be necessary to address complications or to achieve acceptable results. I consent to the performance of such additional procedures if, in the judgment of the surgeon, they are required for my safety or to obtain the intended outcome.

Medical History and Current Health Status

Preoperative and Postoperative Instructions

I agree to follow all preoperative instructions provided by the surgical team, including medication management, fasting, and smoking cessation. I will arrange for a responsible adult to accompany me and assist after the procedure.

I understand that postoperative compliance, including wearing compression garments, attending follow-up visits, and following wound care instructions, is essential to minimize complications and to obtain optimal results.

Consent for Ancillary Actions

By checking the boxes below I indicate my consent for the indicated ancillary actions if they are deemed necessary by my treatment team:

I consent to blood transfusion(s) if required emergently.

I consent to reasonable intraoperative variations or additional procedures if necessary for safety or improved outcome.

I consent to preoperative and postoperative clinical photographs for medical documentation, education, and treatment planning. I understand identifying information will be protected.

I consent to disposal or analysis of tissue or fat removed during the procedure as permitted by law.

HIPAA / Privacy and Release for Treatment

I acknowledge that I have been provided an opportunity to review the facility's privacy practices. I authorize the release of medical information to insurance carriers, other treating providers, and entities involved in my care for purposes of treatment, payment, or healthcare operations as necessary.

I acknowledge receipt of privacy and disclosure information and consent to the uses described above.

Patient Acknowledgment and Certification

I certify that I have read and fully understand this consent form, that the procedure, its risks, benefits, and alternatives were explained to me in terms I understand, and that my questions have been answered to my satisfaction. I understand that I may withdraw my consent at any time prior to the procedure.

Emergency Contact & Insurance

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