I request and authorize Dr. William Lao and/or the associates or assistants of his choice to perform the following operation or procedure(s)
And such additional to alternative therapeutic operations or procedures as his or their judgment may dictate based on findings during the course of said operation or procedure.
Dr. Lao has discussed with and explained to me:
a) The nature and purpose of the operation and/or procedure
b) The possibility that complications may arise and develop
c) The significant risks that may be involved
d) The possible alternative methods of treatment
e) The prognosis if no treatment is received
f) Advance directives (including Do Not Resuscitate orders) are suspended during the operative/special procedure and immediate post operative/special procedure period
Possible complications exist which also include:
Infection, bleeding, injury to surrounding tissue, need for revision, scarring, contour abnormality, failure to achieve desired result, asymmetry, need for further procedure,
I understand that no warranty or guarantee has been made as a result of care. I authorize and direct the above named physician and/or associates to arrange for provisions of such additional services as he/she or they deem reasonable and necessary, including, but not limited to: the administration and maintenance of anesthesia; the transfusion of blood; and the performance of services involving pathology and radiology, with the following exceptions:
Any tissue or parts surgically removed may be retained or disposed of by my physician.
I understand that, at my surgeon's discretion, videotaping and/or photographs may be taken during the course of my care for documentation purposes. I consent to: a) the admittance of authorized observers to the procedure room b) the use of videotaping/photography of my care for educational and marketing purposes, provided that my identity is notrevealedby such pictures or any descriptive text accompanying them.
"I understand that although all reasonable precautions have been taken to ensure that I am not carrying COVID-19, it is possible that I could be carrying COVID-19 and be asymptomatic, despite having had a negative test. I understand that COVID-19 may cause additional risks, some or many of which may not currently be known at this time, as well as, those risks for the treatment/procedure/surgery itself. I understand that this could expose me to increased risk of postoperative complications of even death. I understand all of the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19 and have chosen to move forward with my elective procedure."
RELEASE OF INFORMATION: I authorize the release of medical information to those health care facilities and /or physicians who may be responsible for the patient's follow-up care. I hereby state that I have read and understood the alltheoperation/procedure(s)havebeeninand answeredthat thatabout Consent Form,questionssatisfactorymanner, all blank spaces were filled in prior to my signature.