Breast Implant Patient Understanding and Responsibility
Photographs: I consent to be photographed before, during, and after the treatment. I agree that these photographs become the property of the doctor, to be used as he deems proper. I consent to the publication of these photographs in any medical journal, article, magazine, or book, assuming that my identity will not be revealed. My permission is granted to show these photographs to any other physicians, patients, or persons, although in a confidential manner.
Follow Up Care & Appointments: I agree to keep Dr.Sztulman and Skinsational informed of any change of address and phone numbers, and I agree to cooperate with Dr. Sztulman and his staff in my care after the surgery, until completely discharged from their care. I will make and keep follow up appointments, take medications, and follow other instructions as prescribed.
Postoperative Depression: Common after any form of cosmetic surgery. Such depression is usually related to the immediate postoperative discomfort, drugs, anxiety over a distorted appearance (swelling and bruising) and limitation of activities and socializing. As your appearance improves, and you return to your usual activities and interests, these feelings should disappear.
Medical History: I have given a complete and truthful history of previous surgery and hospitalizations, and all previous physical and mental illnesses, in writing on a separate form, including all medications and drugs that have been taken, or to which I am allergic, or with which I have had (or may still have) a problem of abuse.
Additional Procedures: I authorize the surgeon to perform any other procedures which he may deem necessary or desirable to correct any unforeseen condition encountered during surgery for the purpose indicated above.
Hospital Admission: I understand that treatment of any unusual or serious complication requiring admission to a hospital is not covered by way of cost or charges quoted in connection with this surgery. In addition, I have been made aware that such complications could require the service of additional physicians, and none of these fees or charges are included.
Unknown Risks: Although there are many risks that are known that can be described, there are some risks that are still unknown.
Other Reported Complications after breast augmentation include, but are not limited to: Excessive bruising, swelling, rejection of implants by the body, chronic pain in the breast, chest muscles, or arms for an undetermined amount of time, chronic discharge from the nipple, or cancer of the breast. Although recent studies have not shown an increase in cancer in humans with breast implants, if you choose to have breast implants, you must accept the risk that any material used in breast augmentation (including silicone) may cause cancer during your lifetime.
Long Term Risks: According to the FDA, “The two greatest concerns to most women with implants are cancer and autoimmune disease. But at this time, there is no proven association with breast implants and the development of these diseases.”
Additional costs: Many of the problems known and unknown that can occur and may be related to breast implants may cause the need of additional treatment or surgery. They may also cause prolonged illness, disability, hospitalization, disease, deformity, disfigurement, and death. Any and all of these may require additional expenses and costs to the woman having breast implant surgery, or to her family.
Abnormal Appearance or Feel: Implants are usually detectable. They may look or feel firmer than the normal human breast. They may not move or “jiggle” the same as normal. The implants may be palpable. The valve may be palpable and the implant can often be felt through the skin. They may look “stuck on,” “too high,” “ too low,” or unequal.
Satisfaction: Cosmetic surgery is inexact, and can be complicated. To achieve an improvement in appearance, we undergo serious risks of discomfort, and the distinct possibility of looking worse than we did before the surgery, and being severely disappointed. There can be no guarantee that after the surgery, you or anyone else will be satisfied or pleased with the result.
No Guarantees: I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees have been made to me as to the results of the operation or procedure. It is understood that my results cannot be like any picture or drawings or imaging, or any preconceived idea or goal.
_______ I certify that I am not pregnant, and I will not have sexual vaginal intercourse after the onset of the period before my surgery date for breast surgery
______ I permit visiting physicians or medical personnel to observe my surgery.
______ I agree to avoid aspirin and ibuprofen products, Vitamin E, diet or herbal supplements 2 weeks prior to surgery.
______ I agree not to drive yourself home after surgery and to not drive a car or truck until 48 hours after surgery, assuming that you have not taken any pain medication.
______If I develop a rash, skin infection, open wound or illness anytime prior to surgery, then you will notify Dr. Sztulman’s staff.
Occasionally, Dr. Sztulman will require a letter from your primary care physician to verify your health status. If this letter is not received at least two weeks before surgery, then your augmentation surgery will have to be rescheduled for a later date.
______I understand that the veins on my breasts will be more visible and engorged for at least 4-6 months after the surgery. I also understand that my nipple/areolar area may be mildly to moderately enlarged after this surgery. This enlargement may be permanent.
You must also understand making certain specific sizes of breast might be unreasonable and carry a higher risk of complications. It must be understood by you that we will make every effort to give you the size breast you want, although, this cannot be accomplished in every instance.
If I have any further questions, I will discuss them with Dr. Sztulman before the operation.
_____ I have completely and thoroughly read understand the above Patient Consent and Education sheet and have received a copy of it and have had an opportunity to ask my doctor questions about the product used and its potential complications and I am willing to accept any or all risks associated with breast augmentation as described.
_____ I also understand that Luciano Sztulman, M.D. is a Board-Certified surgeon by the American College of Obstetricians and Gynecologists, he is a Fellow of the American Board of Obstetrics and Gynecology, a Fellow of the American College of Surgeons, a member of the American Society of Cosmeto-Gynecology. He is an experienced Cosmetic Surgeon whom also specializes in Cosmetic and Reconstructive Breast Surgery. I also understand that the American Society of Cosmeto-Gynecology is not a member of the American Board of Medical Specialties, or ABMS.
Quick Breast Implant Facts:
Filled with a saltwater solution similar to the fluid that makes up most of the human body; slightly firmer feel
Flexible fill volume
Smooth High Profile Implant
Covered by Mentor’s standard or enhanced warranty and lifetime replacement policy. (Enhanced warranty is an additional fee paid to Mentor.)
Filled with Mentor’s proprietary cohesive gel formulation that holds together uniformly while retaining the natural give that resembles breast tissue, with set fill volume
Smooth High Profile Implant
Covered by Mentor’s standard or enhanced limited warranty and lifetime replacement policy. (Enhanced warranty is offered with completed paperwork.)
Please note your Patient’s responsibilities:
1. It is the Patient’s responsibility to real all permits and/or consents that he/she signs. If the patient does not understand, it is the patient’s responsibility to ask the nurse or physician for clarification.
2. It is the Patient’s responsibility to answer all medical questions truthfully to the best of his/her knowledge.
3. It is the Patient’s responsibility to read carefully and follow the preoperative instructions that his/her physician has given.
4. It is the Patient’s responsibility to notify the organization if he/she has not followed the preoperative instructions.
5. It is the Patient’s responsibility to provide transportation as directed to and from the organization appropriate to the medications and/or anesthetics that he/she will be receiving.
6. It is the Patient’s responsibility to read carefully and to follow the postoperative instructions that he/she receives from the physician or nurses. This includes postoperative appointments.
7. It is the Patient’s responsibility to contact his/her physician if he/she has any complications.
8. It is the Patient’s responsibility to assure that all payments for services rendered are on a timely basis and that ultimately responsibility for all charges is his/hers, regardless of whatever insurance coverage he/she may have.
9. It is the Patient’s responsibility to notify the Dr. if he/she feels that any of his/her Patient’s principles and rights have been violated or if he/she has a significant complaint or a suggestion to improve services or the quality of care. This should be done in writing; e-mail is not an option.