Trichos Consent Form
CONSENT FOR HAIR TRANSPLANT PROCEDURE
- I, _____________________________________, hereby give consent to
Dr. ____________________________ and his/her hair transplant team to have hair replacement surgery performed upon me. I also consent to any other medical services during the procedure that may become medically reasonable and necessary. This includes, but is not been limited to, the administration of anesthetics and/or sedatives necessary to perform a hair transplant procedure.
- I am aware that good results will depend in part upon my completing the necessary number of operations recommended by the doctor. However, because many variables exist, I have not been promised or guaranteed good results. I also understand that the quality and amount of preexisting hair are major factors in the ultimate result. I understand I will not have hair of the same thickness/density as I had prior to the onset of my hair loss.
- Prior to my consenting to cosmetic surgery, I state I have read or have been given the opportunity to review literature available to me that may include:
- Review of websites
- List of Complications
- Preoperative and post operative instructions
- A fee schedule of current charges per session
I fully understand the results that I may reasonably expect. I understand hair transplants are not perfect. An explanation of this procedure had been given to me. I have had the opportunity to ask any questions regarding this procedure. I do understand that I will not obtain a full head of hair from the procedure. I understand that visibility of the sites following a transplant surgery can last for a number of days.
The pros, cons, and alternatives to hair transplantation have been explained. I have the option of doing nothing, wearing a hairpiece/wig, using prescription medication or having a transplant surgery or other type of scalp surgery procedure. A combination of the above is also possible. I have been informed of all options.
- It is suggested I receive ___________________ sessions(s) of grafts as a minimum. I understand that more operations may be recommended later due to ongoing loss of my non-transplant hair. I understand that all recommendations made during my consultation and treatment are estimates and may change later ________________ (Initial) If the doctors or I feel an additional procedure is necessary, I understand there will be additional surgical fees.
- I understand every time an incision is made in the human body, a scar will occur, although every effort will be made to make the scar inconspicuous. Superficial crusting, pinkness, or redness of the incision area may occur in patients with a history of this type of scarring. Wide scarring is also possible in the donor area.
- I have been informed that hair transplantation is generally a safe procedure; however I am aware that complications may occur. The more common complications and a partial list of rare complications of this surgery have been explained to me and/or I have reviewed a list of them provided which I signed and dated. A copy of that list is attached. Unforeseen, rare complications, such as unanticipated reaction to medications and anesthetics, uncommon infections, and unusual healing responses, are possible. Every unforeseen complication may not have been discussed with me in detail, but I do understand that such risks do exist.
- I consent to and authorized the performance of hair transplant surgery by _____________________,associate doctors, and hair transplant technicians.
- I believe I have been well informed. I understand that good results are expected, but the practices of medicine and surgery are not exact sciences. I understand knowledgeable practitioners sometimes disagree as to the best methods of treatment to achieve desired results.
- It has been explained to me that the amount and location of future hair loss on the scalp, including the sides and back area cannot be predicted. I do understand it is possible to lose my existing hair at any point in the future. I do understand this may affect the appearance of the grafted area. Hair transplants may not be permanent. They are usually very long lasting, but rarely have fallen out in one to ten years.
- There is a possible of some temporary hair loss in the back of the scalp surrounding the area where the donor strip was removed. In rare cases, there may be permanent loss of hair adjacent to the surgical incision. In the transplanted are shedding of existing hair, called surgical effluvium, may occur after the surgery. If this hair is at the end of its normal life span, it may not return.
- I understand the success of the hair transplant procedure is dependent upon my closely following all instructions. This includes, but is not limited to, pre-operative and post-operative activities and precautions, which have been explained to me. I have also received a written copy of these instructions.
- This consent was read and signed while I was not under the influence of medications that might alter my mental capacity to understand its contents.
- I certify this form has been read or it has read to me, the blank spaces have been filled in, and I understand its contents.
- I have disclosed all information regarding past and present medical conditions, current medications, and known drug allergies. This information is necessary so that the proper medical treatment is given at all times during the transplant procedure.
Some postoperative discomfort may be experienced. _______________________ (Initial)
This procedure is offered to obtain the best results for the patient, separate of any profit motive.
I acknowledge I am responsible for payment of these services with no fee reimbursement regardless of procedure results. I understand the fee paid is for the procedure and not for an expected result.
Date: ____________________________ Time ______________________________ AM/PM
Patient or Other Legally Responsible Person Witness
Home Telephone Number
- Nausea and vomiting from pain medication
- Bleeding (less than 5%)
- Infection (less than 1%)
- Excessive swelling
- A temporary headache
- Temporary numbness of the scalp
- Scarring around the grafts
- Poor growth of grafts
- Reaction to medications (less than 1%)
- Fainting (less than 1%) or syncope episodes
- Occasional small-ingrown hairs – causing a cyst (less than 10%)
- Scarring of the donor area – wide scars are possible (less than 5%)
Patients who smoke have a higher rate of delayed wound healing and lower graft yield. Smoking not recommend weeks prior to and following the procedure.
RARE COMPLICATIONS (Partials list only)
- Keloid formation
- Complete failure of growth of transplanted hairs
- Persistent scalp pain
- Total loss of donor hair
- Permanent numbness of the scalp
- Noticeable scarring of donor area
- Loss of transplanted hair
- An allergic reaction or medication-related problem
I have read and understand all the possible complications listed above. I accept the risks of these possible complications and consequences associated with this surgery.
Patient Signature Date
FOR PATIENTS WHO HAVE HAD PRIOR TRANSPLANTS WITH ANOTHER PHYSCIAN:
I acknowledge that prior to contacting _____________________________, I received transplants or scalp reductions from another physician. I further acknowledge _________________________, its physicians and employees bear no responsibility for my present condition. I have been informed that my condition cannot be completely restored to its original state prior to any transplant surgery. ________________ (Initial)
CONSENT FOR ANESTHESIA SERVICES
- All forms of anesthesia involve some risk and no guarantees or promises can be made concerning the results of my procedure of treatment. Although rare and unexpected serve complications with anesthesia can occur and include the remote possibility of infection, bleeding, drug reaction, blood clots, loss of sensation, loss of limb function, paralysis, stroke, brain damage, heart attack, or death.
- I understand the type of anesthesia service (listed below) will be used for my procedure and that the anesthetic technique to be used will be determined by many factors including my physical conditions, the physician’s preference, as well as my own desire.
- Nerve block anesthesia is highly effective and generally safe. In rare cases though, there have been reports of nerve damage. The instances are approximately 1:30,000. Most cases resolve on their own and so not require treatment.
Anesthesia to be used: Major/Minor Nerve block without sedation
Expected results: Temporary loss of feeling and/or movement of a specific area.
Technique: Drug injected near nerves providing loss of sensation to the area of the operation.
Risks: Include but are not limited to, infection, convulsions, weakness, persistent numbness, residual pain, vessels, or nerve injury.
I hereby consent to the anesthesia service described above an authorize its administration by ______________________________ and/or his associates. I also consent to an alternative type of anesthesia if necessary and appropriate.
I certify and acknowledge that I have read this form had it read to me, that I understand the risks, alternative results of the anesthesia service and that I have ample time to ask questions and consider my decision.
Patients’ signature date/time
Responsible party (if other than patient) date/time
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