Healthcare Tummy Tuck Consent Form

HEALTHCARE TUMMY TUCK CONSENT FORM

Patient Information

Date of Birth:    Gender: Female Male Non-binary Prefer not to say

Insurance Information

Medical History

Do you have a history of bleeding disorders? Yes No

Do you smoke or use nicotine products? Yes No

Procedure Details

Surgeon:

Scheduled Procedure Date:

Risks, Complications, and Alternatives

The following risks, while uncommon, are known to be associated with abdominoplasty (tummy tuck) and related anesthesia. I have read and understand each item and have placed my initials beside those items I acknowledge:

A. Bleeding requiring transfusion or return to the operating room — Initials:

B. Infection at the surgical site with possible need for antibiotics or additional surgery — Initials:

C. Poor wound healing, scarring, skin loss, or contour irregularities — Initials:

D. Numbness, persistent pain, sensory changes, or nerve injury — Initials:

E. Asymmetry, need for revision surgery, unsatisfactory cosmetic result — Initials:

F. Blood clots (deep venous thrombosis) and pulmonary embolus, which can be life-threatening — Initials:

Alternatives to the proposed procedure include: non-surgical management, delayed surgery, liposuction alone, or no treatment. I have had an opportunity to discuss reasonable alternative treatments and the risks of refusing surgery.

Anesthesia and Related Consent

I understand that anesthesia, whether general, local with sedation, or other modalities, involves risks including allergic reaction, respiratory complications, cardiac events, and even death. I authorize the administration of anesthesia determined by the anesthesiologist in the best interest of my safety.

Consent for Photography and Medical Records

I consent to preoperative and postoperative photography for clinical documentation and treatment planning. I understand that photographs may be used for education or scientific purposes only if my identity is not revealed without separate written authorization.

I authorize the release of medical information to other healthcare providers involved in my care and to my insurer as necessary for treatment, payment, and healthcare operations. This authorization expires on:

Financial Responsibility

I understand that I am financially responsible for charges not covered by insurance, including surgeon, facility, anesthesia, and pathology fees. I accept responsibility for payment in accordance with the practice's billing policies.

I acknowledge that no guarantee has been made to me regarding the results of the surgery.

Patient Acknowledgements and Consent

By signing below I certify that: (a) I have read and understand this consent form and had the opportunity to ask questions; (b) the nature and purpose of the proposed tummy tuck, the expected benefits, the material risks, and reasonable alternatives have been explained to me; (c) no guarantees have been made as to the results; and (d) I consent to the performance of the procedure described above, including any additional procedures that are found to be necessary during surgery for my safety or to achieve the intended result.

I understand that I may withdraw consent at any time prior to the administration of anesthesia and that withdrawal will not affect my right to future care or treatment.

HIPAA Privacy Notice: I acknowledge that I have received or been offered the practice's privacy notice describing how my medical information may be used and disclosed. I understand my rights regarding my protected health information.

Patient agrees to the above: Yes

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