CONSENT FOR PROCEDURE OR TREATMENT
1. I permit Dr. David Rankin and the doctor’s assistants to do the procedure Breast Implant Removal.
2. I got the information sheet on Breast Implant Removal.
3. I understand that, during the surgery, an unexpected situation may require a different medical procedure than the surgery listed above. I permit the doctor listed above, the assistants and/or designees to provide any treatment that my doctor thinks is needed or helpful. My permission includes all treatments that my doctor does not plan to do at the start of the surgery.
4. I understand what my surgeon can and cannot do. I understand that no warranties or guarantees have been hinted at or stated outright about the outcome of the surgery. I have explained my goals. I understand which outcomes are realistic and which are not. All my questions have been answered. I understand the surgery’s risks. I am aware of other risks and possible issues, benefits, and options. I understand and choose to have the surgery.
5. I agree to the anesthetics that are needed or helpful. I understand that all types of anesthesia have risks and may result in complications, injury, and even death.
6. I am aware of the serious risks to my health when blood products are used. I agree to my doctor using them if my doctor, assistants, and/or designees think they are needed or helpful.
7. I agree to the disposal of any tissue, medical devices, or body parts taken out during or after surgery. I also agree to any additional surgeries or treatment that is needed or helpful.
8. I agree to have parts of my body photographed or televised appropriately before, during, and after the surgery for medical, scientific, or educational reasons, if the pictures do not reveal my identity.
9. For medical education, I agree that onlookers can be in the operating room.
10. I permit my Social Security Number to be given to the right agencies for legal reasons and medical device registration, when necessary.
11. I agree to the charges for this surgery. I understand that the doctor’s charges are separate from the charges for the hospital and the anesthesia. I understand that there may be more charges if more procedures or treatments are needed or helpful. I agree to those charges, if any.
12. I understand that not having the surgery is an option and that I can opt-out of having the surgery.
13. IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
a. THE ABOVE SURGERY TO BE PERFORMED
b. THERE MAY BE OTHER SURGERIES OR TREATMENT OPTIONS
c. THERE ARE RISKS TO THE SURGERY
I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED ITEMS (1-13).
I AM SATISFIED WITH THE EXPLANATION.