Liposuction Consent Form - Arizonaveinandlaser.com

Kulbhushan Sharma, MD., PC. Arizona Vein & Laser Institute & Cosmetic Surgery/Med Spa 5620 W. Thunderbird Rd. Ste. D-4 Glendale, AZ 85306 (602) 298-5476

Audio/Video/Photo Use Consent Form _______________________________ Client's Name (Please Print)

__________________ Date

I permit AZ Vein & Laser & Cosmetic Surgery Med Spa to record, own, republish pictures of me/my property and reproductions of my likeness and my voice for educational, marketing, and publicity purposes through any media. I acknowledge that the pictures or recordings taken on this date then become the sole and exclusive property of AZ Vein & Laser & Cosmetic Surgery Med Spa. I release AZ Vein & Laser & Cosmetic Surgery Med Spa and it's agencies from any and all claims that might arise from use of these images and recordings.

____________________________ Patient’s Signature

____________________________ Patient Printed Name

____________________________ Witness Signature

_______ Date

___________ Date

Kulbhushan Sharma, MD., PC. Arizona Vein & Laser Institute

& Cosmetic Surgery/Med Spa 5620 W. Thunderbird Rd. Ste. D-4 Glendale, AZ 85306 (602) 298-5476 Waiver of Liability _____Insurance companies will only pay for services that are determined to be "reasonable and necessary." The procedure you are having is an elective and/or cosmetic procedure and therefore, not determined "reasonable and necessary" under insurance standards. Elective and/or cosmetic procedures are done on a cash-only basis and therefore our office does not bill insurance companies for these procedures. _____I have been notified that in my case insurance will deny payment for the service(s) identified below for the reason stated. I agree to be personally responsible for payment in full. _____By signing this waiver of liability, I acknowledge that this is an elective and/or cosmetic procedure and is not covered by any insurance plan. I further acknowledge that my physician and/or his representatives will not bill and insurance company on my behalf, nor will they accept any payment from any insurance company for this procedure. _____I understand that treatment of any unusual or serious complications 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. Procedure(s):___________________________________________________________________________ Date:_______________

Charges:____________________ ____________________ ____________________ ____________________ TOTAL:_____________

Patient Signature__________________________

Patient Printed Name________________________

Witness Signature_________________________

Witness Printed Name________________________

Kulbhushan Sharma, MD., PC. Arizona Vein & Laser Institute & Cosmetic Surgery/Med Spa

5620 W. Thunderbird Rd. Ste. D-4 Glendale, AZ 85306 (602) 298-5476

COMPANY POLICY ALL procedures must be paid in full before surgery date

PAYMENT TYPES & REFUND POLICY 1. 50% of the total surgery cost is due in our office 7 days prior to the surgery date. 2. If a payment is made by check, it must be in our office ten days before the surgery. 3. If you are paying with cash, money orders, or travelers checks, the remaining 50% may be paid the day of surgery but before the preparation of surgery. 4. A minimum of $500.00 deposit is required to book and hold the surgery date. This date can be rescheduled two or more weeks prior to surgery. Should you need to reschedule, please call our office as soon as possible. The deposit is non refundable under any circumstances. 5. Total payment made for the surgery is non-refundable if the surgery is cancelled within one week of the scheduled date. Fifty percent (minus the deposit) refund is applicable if surgery is cancelled two or more weeks prior to the procedure.

Patient Signature:__________________________________

Date:__________________

Patient Printed Name:________________________________

Witness Signature:__________________________________

Date:__________________

Kulbhushan Sharma, MD., PC. Arizona Vein & Laser Institute & Cosmetic Surgery/Med Spa 5620 W. Thunderbird Rd. Ste. D-4 Glendale, AZ 85306 (602) 298-5476 www.ArizonaVeinandLaser.com

Lidocaine Consent Have you ever been administered lidocaine?

Yes_____ No_____

If yes, how was it administered (e.g. topically, injected)__________________________ Did you have any adverse reactions or complications from lidocaine? Yes_____ No_____ If yes, please explain______________________________________________________

I, ______________________________ state that the above is answered truthfully, to the best of my knowledge.

Signature:____________________________________

Date:_________________

Witness:_____________________________________

Date:_________________

Kulbhushan Sharma, MD., PC. Arizona Vein & Laser Institute & Cosmetic Surgery Medspa 5620 W. Thunderbird Rd. Suite D-4 Glendale, AZ 85306 (602) 298-5476 www.ArizonaVeinandLaser.com

Liposuction Pre-Operative Checklist Patient Name:___________________________ Date:______________

Please initial each item to acknowledge that you agree and understand all of the following: Please print “NO” if you disagree. _________ We may telephone you at the following numbers: ______________________ and ______________________ _________ You agree to avoid ASPRIN and IBUPROFEN for ten (10) days prior to surgery, and to avoid DECONGESTANTS for five (5) days prior to surgery, and do not take FASTIN (phentermine), ZOLOFT, and ALL HERBAL REMEDIES for two weeks prior to surgery. _________ If another physician prescribes any medications for you, then you will contact and inform our medical staff at that time. _________ If you develop a rash, skin infection, an open wound, bladder infection, respiratory infection, or any other illness at any time prior to surgery, then you will contact and inform our medical staff at that time. _________ If your pre-op exam and/or lab work are done out of town by another doctor, then you guarantee that the results will arrive at our office at least two weeks prior to surgery. Otherwise, your surgery may have to be rescheduled. _________ If your surgeon requires clearance from your primary care physician to verify your health status, then you guarantee that the letter will arrive at our office at least two (2) weeks prior to surgery. _________ I consent to the routine pre-operative laboratory studies including an HIV test. The results of these tests will be placed in the patient’s chart and remain confidential. _________ If you have any doubt about being pregnant, please inform the doctor and/or staff immediately. I have read this entire pre-operative checklist form and initialed each item acknowledging that I understand and agree. Patient Signature:_____________________________________ Date:__________________


Arnica Tea

Arnica tea will significantly reduce inflammation, bruising, and swelling. We highly recommend drinking arnica tea 4-5 times a day. It can be found at many health food stores as well as Sprouts Farmer’s Market.

How to Prepare Arnica Tea:     

Boil 2 liters of water for 15 minutes Add 1 spoon of arnica tea (dry flowers) Filter Drink tea warm or cold Add honey or sugar to taste


PRETREATMENT INSTRUCTIONS ***PLEASE READ ALL OF THESE INSTRUCTIONS CAREFULLY**  If you suspect you may be pregnant, please inform the doctor and staff.  Medications will be prescribed. Please fill the prescriptions and take the as indicated.  You should not plan to drive yourself home. Please have a friend or designated driver to take you home on the day of surgery.  It is in your best interest to have someone available to be with you the first 24-48 hours after surgery.  If you take a blood thinner (aspirin, Coumadin, Plavix, etc.), or any other prescribed and over the counter medications, please let us know as this affects your care.

 DO NOT drink alcohol for one week prior to surgery as this might cause excessive bleeding.  DO NOT take aspirin, ibuprofen, Fastin (phentermine), Zoloft, Multi-vitamins, St. John’s Wort, vitamin E, and ALL HERBAL remedies for two (2) weeks prior to surgery and AVOID decongestants for two (2) weeks prior to surgery. DO NOT take Zoloft or other antidepressants, unless specifically approved by your surgeon, for two (2) weeks before surgeries.  Drink 1-2 quarts of water daily for one week prior to the procedure.  Please bathe the day of the procedure. You will not be able to shower for 2 days after the procedure.  Prior to the procedure, have a normal meal.  Do not apply any creams or makeup the day of the procedure.  Please bring extra clothes (comfortable pants/shorts, shirt, and underclothes). A button up shirt may be easier to remove once you get home. I have read the above instructions. I understand and agree to comply with them fully.

Patient Signature:__________________________________

Date:__________________

Arizona Vein & Laser Institute & Cosmetic Surgery Medspa 5620 W. Thunderbird Rd. Suite D-4 Glendale, AZ 85306 (602) 298-5476 www.ArizonaVeinandLaser.com

Patient Advisement Dr. Sharma is thankful for the opportunity to improve your aesthetic beauty. While we are certain that you will appreciate and enjoy your new look, we must caution you to be realistic in your expectations. We can only do what you have paid us to do. THERE ARE NO GUARANTEES YOU WILL END UP LOOKING PERFECT. With liposuction you can expect a 50-70% improvement. We can remove only a limited amount safely. Breast augmentations do not change the position of nipples nor does it create new cleavage. Our procedures are performed under local anesthesia so you are aware, awake, and involved during your procedure. While we strive for your satisfaction and we are happy to perform any additional procedures, you will be charged for any additional procedures. No FREE work, touch ups, or additional work will be provided without cost. You have been advised of your responsibilities following your procedure and have received written instructions which you MUST follow. You have also been apprised of the need to be realistic about expectations and the improvement you should expect to see. You have also had the opportunity to see before and after pictures to provide you with an idea of what expectations to have. Our website, www.arizonaveinandlaser.com has many

before and after pictures. I understand that tumescent liposuction is not recommended for certain patients and that I am not one of these patients listed below: Women who are pregnant or believe they might be pregnant Women who are nursing Patients with active thrombophlebitis or active infection Patients with poor circulation or confined to bed Patients with a history of pulmonary embolism or blood clots in the lungs Patients with a history of severe or multiple allergic reactions Patients with uncontrolled diabetes mellitus or uncontrolled collagen vascular disease Patients with a history of uncontrolled bleeding Patients with positive blood tests for HIV, AIDS Patient Initial______ By signing this document, I am acknowledging that I have read and understand the above mentioned.

Patient Signature:_____________________

Date:_________

Printed Name:________________________ Kulbhushan Sharma, MD., PC. Arizona Vein & Laser Institute & Cosmetic Surgery Medspa 5620 W. Thunderbird Rd. Suite D-4 Glendale, AZ 85306 (602) 298-5476 www.ArizonaVeinandLaser.com

Patient Acknowledgement I have read over all pages and discussed the pre-operative and post-operative instructions in detail at my pre-operative consultations. I have had the opportunity to ask questions and to go through the paperwork thoroughly. I agree to follow the pre and post operative instructions. I understand there is no guarantee and I have realistic expectations for my surgery and appearance after. These papers were given to me,____________________, on ___________. Patient Signature:_____________________ Printed Name:________________________

Date:_________


Post Operative Garments We will provide you with a post operative garment on the day of your procedure. We ask you to wear this garment for 48 hours following your procedure. After the 48 hours, you will wear a garment that you need to purchase.

Garments can be purchased at:  Annette.com  Lipoinabox.com  Makemeheal.com

Garments can also be found in the lingerie section of any major department store. These may be known as body shapers or Spanx.

   

Macy’s Nordstrom’s Target Most sporting goods stores

You want a light support garment (nothing tight). When buying the garment keep in mind that you want the garment to go above and below the areas treated (ex: For inner thigh lipo the garment needs to go below the knee). If you have any questions please call the office at (602) 298-5476.


IMPORTANT INFORMATION Dear Patient, Please check your wound(s) daily and call us if you are experiencing any of the following:  Opening of the wound  Any secretion from the wound  Fever  Severe Pain  Foul smell from the incision site  Redness around incision area  Increasing swelling  Any other concerning symptom Our information, including phone numbers is: Arizona Vein and Laser Institute 5620 W. Thunderbird Rd. Ste. D-4 Glendale, AZ 85306 (602) 298-5476 or (602) 547-2690 Our goal is to achieve the best results possible from your aesthetic surgery. It is important that you

are aware of any complication signs and symptoms during your recovery period. We will be assessing you during your follow up appointments but you are also responsible for taking care of your wounds daily. You are also responsible to inform us immediately of any above symptoms. Remember that if you are unsatisfied with the outcome, you are responsible for any additional expense that may arise. I have read the above and fully understand my responsibilities. Patient's Name:__________________ Patient Signature:_________________ Date:________ Arizona Vein & Laser Institute &Cosmetic Surgery/Med Spa 5620 W. Thunderbird Suite D4 Glendale, AZ 85306Page 1 Lipo (602) 298-5476 CONSENT FOR TUMESCENT LIPOSUCTION/ SMARTLIPO Patient:_______________________________

Date:______________

I hereby authorize Dr. Sharma to perform tumescent liposuction/Smartlipo on me on the following area(s): ______________________________________________ I am aware that additional staff members may be assisting during the procedure. I fully understand that this procedure has limited application. No guarantee or assurance has been given to me by anyone as to the results that may be obtained. I am aware that the practice of medicine/surgery is not an exact science, and I acknowledge that no guarantees have been made to me as to the results of the procedure(s). I request and authorize Kulbhushan Sharma, MD to perform Smartlipo on me. The nature and effects of the procedure, the risks, ramifications, complications involved, as well as alternative methods of treatment have been fully explained to me by Dr. Sharma and/or his staff at Arizona Vein and Laser Institute, and I understand them. I have been thoroughly and completely advised regarding the objectives of the procedure. Because I understand that the practice of medicine and surgery is not an exact science, I am aware that no results have been guaranteed. I acknowledge that imperfections might ensue and that the operative result nay not live up to my expectations. I certify that no guarantees have been made by anyone regarding the procedure(s) I have requested and authorized. I understand that in the unlikely case where an imperfection results that the patient and the doctor determine the necessity of a secondary procedure, such revisions are not included in the initial fees. I understand that I may be required to wear the garment continuously for 3-4 days and removal is only permitted with Dr. Sharma’s and/or the staff at Arizona Vein and Laser Institute’s recommendation. I understand that the possible adverse effects may include bleeding, infection, scarring, skin contour irregularities, asymmetry, surgical shock, pulmonary complications, skin loss, seroma, allergic reaction and anesthesia related complications can occur and should be discussed and understood. The patient must understand the importance of pre-treatment and post-treatment instructions and that the failure to comply with these instructions may increase Page 1 Lipo

the possibility of complications. I recognize that during the course of the operation, unforeseen conditions may necessitate additional or different procedures other than those above. I therefore further authorize and request that Dr. Sharma may perform the procedure(s) that are in his professional judgment as necessary and desirable. I understand that local and tumescent anesthesia is normally required when liposuction is performed. I consent to this treatment. Photographs will be taken of the region of treatment and I give permission for these photographs to be used for the purposes of publications, training, education, or sales purposes. If I do not agree to being photographed, it will in no way affect my present or future care. I agree to have photographs taken as described in this form

YES

NO

I certify that I have read the above authorization, that the explanations referred to therein were made to my satisfaction, and that I fully understand such explanations and the above authorization. Dr. Sharma and/or his employees have discussed in detail with me. Tumescent liposuction/ Smartlipo is a body contouring and sculpting technique. It is a means of reducing localized fat deposits that are difficult or impossible to remove with diet and exercise. Tumescent liposuction/Smartlipo is not for treating obesity. Tumescent anesthetic is injected into the fatty tissue before it is removed. After the procedure, compression garments are worn for drainage and support. I clearly understand and accept the following:  The goal of tumescent liposuction/Smartlipo is to improve, not perfect, the treatment area.  The final results may not be apparent for 3-6 months (or more) post procedure.  In order to achieve the best results possible, a "touch-up" procedure may be required.  Areas of cellulite will be changed little by tumescent liposuction/ Smartlipo.  Tumescent liposuction/Smartlipo is a contouring/sculpting procedure and is not performed for purposes of weight reduction, nor a substitute for healthy dieting and exercise.  Strict adherence to the post-operative regimen and instructions is necessary in order to achieve the best results.  I must not have taken aspirin-containing products for a minimum of two weeks prior to my surgery.  There is no guarantee expressed or implied that the expected or anticipated results will be achieved.  I understand that tumescent liposuction/Smartlipo is not recommended for certain patients and that I am not one of these patients listed below: Women who are pregnant or believe they might be pregnant Women who are nursing Patients with active thrombophlebitis or active infection Patients with poor circulation or confined to bed Patients with a history of pulmonary embolism or blood clots in the lungs Patients with a history of severe or multiple allergic reactions Patients with uncontrolled diabetes mellitus or uncontrolled collagen vascular disease Patients with a history of uncontrolled bleeding Patients with positive blood tests for HIV, AIDS Patient Initial______ Although complications following tumescent liposuction/Smartlipo are infrequent, I understand the following may occur:  Skin irregularities, lumpiness, hardness, and dimpling may appear post operatively. Most of these

irregularities may persist permanently.     

  

 

Infection is rare but should it occur, treatment with antibiotics and/or surgical drainage may be required. Numbness or increased sensitivity of the ski over the treated area(s) may persist for months. Rarely, localized areas of numbness or increased sensitivity could be permanent. Typical, temporary side effects associated with tumescent liposuction includes soreness, inflammation, bruising, swelling, numbness, and minor irregularities with the skin. Some of these effects can take several months to resolve. Objectionable scarring or pigment changes are unusual because of the small size of the incisions used in tumescent liposuction, but scar formation or permanent pigmentation are possible. Dizziness mat occur during the first 24 to 48 hours following the tumescent liposuction/Smartlipo, particularly upon rising from a lying or sitting position, or when removing compression garments. If this occurs, extreme caution must be taken while walking. Do not attempt to drive a car or operate heavy machinery if dizziness is present. Surgical bleeding is very rare using tumescent liposuction; however it could require hospitalization. Temporary accumulation of fluid under the skin (seroma) may occur, requiring possible surgical drainage. In addition to these possible complications, I am aware of the general risks inherent in all surgical procedures and anesthetic administration. Although rare with tumescent liposuction/Smartlipo, unexpected, severe complications can occur, including but not limited to; allergic reaction, paralysis, blood clots, stroke, heart attack, brain damage, or even death. In the event of an emergency, I hereby give my consent to be transferred to the nearest hospital. I understand that I am responsible for my expenses while in transit between institutions as well as any hospital, physician, laboratory, or radiological expenses for my care during that time. I confirm that Dr. Sharma and his staff have explained to me the nature, purpose, limitations, possible consequences and risks involved with tumescent liposuction/Smartlipo. I understand this explanation and comprehend that other, more remote risks and consequences may arise. I have been advised that a more detailed explanation of my foregoing matters will be given to me as I so desire and I do not desire such further explanation. All questions have been answered to my satisfaction.

Patient Signature__________________________




Date_____________

Date_____________

Dr. Sharma/Staff Declaration: I have explained the contents of this documentation to the patient and have answered all the patient’s questions, and to the best of my knowledge. The patient has been adequately informed and has consented. Witness Signature__________________________


Physician Signature_________________________

Physician Printed Name________________________

Kulbhushan Sharma, MD., PC.

Date_____________

Date_____________

Arizona Vein & Laser Institute & Cosmetic Surgery Medspa 5620 W. Thunderbird Rd. Suite D-4 Glendale, AZ 85306 (602) 298-5476 www.ArizonaVeinandLaser.com

Liposuction Post-Operative Instructions Patient Name:___________________________ Date:______________ ♦ DO NOT TAKE ASPRIN, IBUPROFEN, NAPROXEN, or any other non-steroidal anti-inflammatory drugs (NSAIDS) for 10 days prior to your surgery and ♦ After your two day follow up appointment you will begin massaging the treated area as instructed by Dr. Sharma ♦ After your two day follow up, you will wear the compression garment you purchased. You will wear this garment for 4-6 weeks to ensure the best results. ♦ Do not shower or remove your dressing for two days. However, you may change the absorbent pads as often as needed. ♦ Do not drink alcohol for 2weeks after your procedure. ♦ Continue to take your medication as prescribed. Continue your antibiotics until your prescription is finished. You will receive pain medication to take as needed in addition to your other prescriptions. ♦ When removing your bandages for the first time, sit down and slowly take the garments off to avoid dizziness and/or fainting.

Patient Signature:_____________________________________ Date:__________________

Kulbhushan Sharma, MD., PC. Arizona Vein & Laser Institute & Cosmetic Surgery/Med Spa 5620 W. Thunderbird Rd. Ste. D-4

Glendale, AZ 85306 (602) 298-5476

Waiver of Liability I, _______________________________, have been instructed to quit smoking 2 weeks prior to, and for 2 weeks post procedure. I understand that smoking may prolong my healing resulting in possible infection, poor healing, necrosis or dying of the skin, discoloration, bad scarring, or other possible side effects. These possible complications may require additional surgeries/procedures including skin grafts and various other treatments. I understand that even with smoking cessation, there is a possibility of infection, dying skin, bad scarring, and other side effects. I understand all of the risks and possible complications and have been given the opportunity to ask any questions that I might have. I understand that this surgery differs from previous surgeries I may have had in which I healed well. Patient Signature__________________________


Date_____________



Date_____________



Date_____________