Healthcare Plastic Policy

HEALTHCARE PLASTIC POLICY

This Healthcare Plastic Policy and Informed Consent governs the provision of elective and reconstructive plastic surgery, related ancillary procedures, perioperative care, and the handling of photographic and medical records. Patient acknowledges receipt, understanding, and acceptance of the terms and consents herein by signing at the end of this document.

Patient Information

Insurance Information

Medical History

Procedure Description and Consent

The surgeon named below will explain the purpose, expected benefits, material risks, likely outcomes, and reasonable alternatives to the planned procedure. I understand that no guarantee is made as to the results. Surgeon:

Risks, Complications, and Expected Outcomes

I acknowledge that plastic surgery and associated anesthesia involve risks which may include, but are not limited to: infection, bleeding, hematoma, seroma, scarring, asymmetry, poor wound healing, sensory change or numbness, adverse reaction to implants or grafts, necrosis, need for revision surgery, anesthesia complications, thromboembolic events, and death. Unanticipated complications may require additional treatment or hospitalization.

Alternatives and Right to Withdraw

I have been informed of reasonable alternatives to the proposed procedure, including nonsurgical options, watchful waiting, and alternative surgical techniques. I retain the right to refuse or withdraw consent at any time prior to the procedure without penalty.

Anesthesia and Blood Products

I understand anesthesia options include local, regional, intravenous sedation, and general anesthesia. I consent to the administration of anesthesia as recommended by the anesthesia team and accept associated risks. Anesthesia type discussed: Local Sedation General

I consent to blood transfusion or blood product administration if deemed necessary for my safety: Yes No

Implants, Allografts, and Materials

If implants, prostheses, or biologic materials are planned or discovered to be necessary, I consent to their use. I acknowledge different implant types carry specific risks including device failure, need for removal, and long-term surveillance. Do you consent to the use of implants/allografts if indicated? Yes No

Photography and Medical Records

Preoperative, intraoperative, and postoperative photographic documentation is an essential part of care and medical records. I consent to medical photography for clinical documentation and treatment planning. For educational or promotional use, separate consent is required.

Photography consent for clinical records: Yes No

Photography consent for educational or promotional use (explicit additional consent required): Yes No

Financial and Cancellation Policy

I understand that elective plastic surgery may be self-pay or partially covered by insurance. I accept financial responsibility for all fees not covered by insurance including surgeon, facility, anesthesia, and ancillary costs. I acknowledge the facility's cancellation, rescheduling, and no-show policies have been explained.

HIPAA and Release of Information

I acknowledge that I have received the facility's privacy practices and understand my protected health information will be used for treatment, payment, and healthcare operations in accordance with applicable law. I authorize the release of medical information as necessary to process insurance claims and to provide continuity of care.

HIPAA Acknowledgment: I acknowledge receipt of the privacy practices and authorize release of necessary medical information.

Patient Acknowledgment and Certification

By signing below I certify that: I have read this policy or it has been read to me; I understand the information provided; I have had the opportunity to ask questions and have received satisfactory answers; I consent to the planned procedure(s), associated anesthesia, use of implants if indicated, and the release of medical information as described above. I understand consent may be withdrawn prior to the procedure.

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