Healthcare Patient Rhinoplasty Consent Form

HEALTHCARE PATIENT RHINOPLASTY CONSENT FORM

Patient Information

Date of Birth:

Emergency Contact

Insurance Information

Medical History

I have a history of bleeding disorder or abnormal bleeding.

I currently smoke or use nicotine products.

If patient is female: I am pregnant or may be pregnant.

I have had prior problems or reactions to anesthesia.

Procedure Description and Authorization

I hereby authorize the physician and such assistants as may be selected to perform the procedure described above and such additional procedures as are necessary or advisable in the professional judgment of the surgeon to treat conditions discovered during the procedure. I authorize the administration of anesthesia and related care as indicated. I understand that surgery involves both known and unknown risks and that no guarantee has been made as to the results.

Risks and Complications

The common and less-common risks specific to rhinoplasty include, but are not limited to: bleeding, infection, poor wound healing, visible scarring, asymmetric or unsatisfactory aesthetic result, persistent nasal obstruction, alteration or loss of smell, septal perforation, graft displacement or resorption, need for revision surgery, prolonged swelling or bruising, numbness or altered sensation, skin discoloration, and complications related to the use of grafts or implants. Rare but serious complications may include severe infection, airway compromise, deep vein thrombosis, pulmonary complications, cardiac events, or death. Anesthesia carries its own risks including allergic reaction and respiratory or cardiac complications.

I acknowledge that outcomes cannot be guaranteed and that additional surgery may be necessary to achieve the desired result or to address complications. I have been informed of the possibility of revision surgery and understand the financial and medical implications.

Alternatives and Benefits

Reasonable alternatives to the proposed procedure were explained, including non-surgical management, deferral of surgery, and secondary procedures. Potential benefits include improved nasal appearance and/or improved nasal airflow. I accept that improvement in appearance is subjective and that perfect symmetry is not assured.

Additional Authorizations and Acknowledgements

I consent to intraoperative decisions deemed necessary by the surgeon, including trimming of bone and cartilage, use of graft material (autograft, allograft or implant), placement of internal or external splints, packing, suturing, and any incidental ancillary procedures required for safe completion of surgery.

I authorize preoperative and postoperative photography for medical records, surgical planning, and educational purposes. I understand that these images are part of my medical record.

I acknowledge that I have been advised of typical postoperative care, activity restrictions, and the importance of follow-up visits. I agree to comply with postoperative instructions and to notify the surgeon promptly of any concerns.

I consent to clinical photography as described above.

I consent to the use of grafts or implants as necessary.

In the event blood transfusion is medically indicated, I consent to the transfusion of blood or blood products.

Financial Responsibility

I understand that I am financially responsible for fees related to the procedure, hospital/facility charges, anesthesia, and any additional treatment required for complications. Insurance coverage is not guaranteed and I remain ultimately responsible for payment.

HIPAA / Privacy Acknowledgement

I acknowledge receipt of the facility's privacy practices and understand how my medical information may be used and disclosed for treatment, payment, and healthcare operations.

Authorization Expiration

This authorization is valid until:

Patient Questions and Notes

By signing below I certify that I have read and fully understand this consent form, that the nature and purpose of the procedure, the risks, benefits, alternatives and probable outcome(s) have been explained to my satisfaction, and that all of my questions have been answered. I understand that I may withdraw my consent at any time prior to the procedure.

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