INFORMED CONSENT FOR PLASTIC SURGERY
It is a legal requirement that before any surgical operation the patient reads and signs a consent form. Please do not hesitate to ask Dr.Aniruddha Bose or his nurse any queries arising from this form.
Date of Surgery:
1.I hereby request and authorise Dr Aniruddha Bose aided by assistants he may choose to use and/or require to perform upon myself the following operation on or about the above date surgery
In medical terms the name of the procedure is:
2. I have carefully read the information in his website pertinent to the proposed surgery and understand the information. Furthermore, Dr Aniruddha Bose has fully explainedin terms clear to me, the effect and nature of the opersion(s) to be performed, the foreseeable risks risks involved, and alternative methods of treatment, as well as what I can expect to experience if recovery is uneventful. Most patients have surgery with little difficulty but problems can happen from minor to even fatal. Lastly, I acknowledge that I have been given an oppurtunity to ask queestions I desire regarding the matters contained in the preceding three sentences and that these questions have been answered to my satisfaction.
3. I also authorise Dr Aniruddha Boseand his assistants to perform any other procedures which he may deem necessary or desirable in attempting to achieve the object of the operation(s) or the elimination of any unhealthy or unforeseen condition that he may encounter during the operation(s).
4. I consent to the adminstration of anaesthetics and medications to be applied by or under the direction of Dr Aniruddha Bose and to the use of such anaesthetics and medications as he may deem advisable in my case with the exception of:
To the best of my knowledge, I am only allergic to:
5. It is possible that the result might not live up to my expecations or the goals that have been established. I understand the practice of medicine and surgery is not an exact science and therefore reputable physicians cannot guarantee results. I acknowledge that no guarantee or assurance has been made ny anyone regarding the operation(s) which I have rein requested and authorised.
6. I have been advised that part of this surgery is, or maybe, performed through external excisions of skin which will leave permanent scars, wgose extent and location has been described to me. I have been advised that scars take upwards of one year or more to mature and the changes normally occur in their appearance during the healing period have been described to me. The locations of the scars have been indicated to me by Dr Aniruddha Bose.
7. I hereby give permission to Dr Anirudda Bose or any assistant he may require to take photographs for diagnostic purposes and to enhance medical record. I agree that these photographs will remain in his possession. I further authorise him to use such photographs for teaching purposes or to illlustrate scientific papers, books or lectures in his judgement medical research, education or science will be benefited by their use. It is specifically understood that in any such publication or use I shall not be identified ny name.
8. I understand that if Dr Aniruddha Bosejedges at anytime that my surgery should be postponed or cancelled for any reason, he may do so.
9. I also understand that I am free to withhold or withdraw my consent at anytime before the surgery without effecting my right to future care or treatment.
10. I agree to follow the instructions given to me by Dr Aniruddha Bose to the best of my ability before, during and after the above-named surgical procedure.
11. I heraby state that the information I gave during my diagnostic evaluation is correct.
Witness’ Signature (Not A Member Of Patient’s Family)
I certify that all blanks in this form were filled in prior to above signatures and I explained them to he patient before asking the patient to sign.
Signature of Aniruddha Bose
MBBS, FRCS, Diplomate NB, FICS, FISBI
Senior Consultant Plastic, Cosmetic & Reconstructive Surgeon