1. Patient Information

2. Consultation of Surgeon

Through this document I have explained to the customer:

• About the customer's current condition, cosmetic surgery / procedures demand and the result of this surgery, others related treatments, risks for cosmetic technique options. The result of cosmetic surgery is a relative assessment that cannot be specifically measured. Basically, we are going to respond the customer's requirements for each specific cosmetic surgery.
• Re-surgery may be required if the aesthetics is unsatisfactory.
• Accidents and complications can occur in the surgery and procedures. Depending on the type of the surgery, there are some typical complications:
  • Bleeding during and after surgery, post-operative infection, seroma, haematoma from the surgical wound.
  • For rhinoplasty surgery: The nose maybe deviated after surgery. Implants may need to be removed if they cause an allergic reaction or infection after surgery.
  • For breast plastic surgery, breast augmentation: displacement implants, pneumothorax, removal of implants due to not adaptation of body, nipple necrosis.
  • For liposuction, fat grafting surgery and abdominoplasty: haematoma, blood loss that may require blood transfusion during or after surgery, seroma, lymphedema and abdominal trauma with injury organs (liver, intestines,...), or necrotic inflammatory abdominal skin, injury to lungs, pleura, bilateral chest, reduced or loss of vision, coronary fat embolism, deep vein thrombosis, occlusion pulmonary embolism, pulmonary edema, fat embolism and even death.
• Not to require to take photo or film during or after surgery.
• I have provided customer/relatives with the above information. I have allowed enough time for the customer/relatives to ask questions related to the surgery/procedure and I have answered those questions. I have believed that customer/relatives understand what I have explained. I explained to the customer that the customer's decision is personal and the customer will have to decide which benefit will achieve his/her goal and whether the risks and complications are acceptable or not.

3. Confirmed by Customer/Relatives

is my/my relatives doctor, who provided me this surgery/procedures consultation form. The doctor gave me the information about my/my relatives conditions and chose the appropriate surgery/procedure.

It has been explained to me and I understand that the addition procedures/tests/treatments may be required during the surgery/procedures and the post-surgery because of conditions or complications that cannot be avoided. I allow the addition procedures/surgery/tests/treatments if it is necessary to save my/my relatives life or prevent serious harm. I accept that if accidents or complications can occur, I will not sue the doctor or hospital. The hospital and doctors are responsible for treating me if accidents and complications occur.

The witness signs below if the patient is unable to sign but he/she has consented.

4. Signatures