115 SW Allen Road
Bend, Or 97702
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Consent Form for Blepharoplasty

PATIENT__________________ DOB __/__/__

I, __________________, hereby authorize Dr. Van Camp and his associates and staff to perform eyelid surgery (blepharoplasty) on me. I understand the nature and purpose of this procedure, and that this procedure has limitations and risks. The alternatives, including no treatment, and known risks have been explained to me and I have had all of my questions answered to my satisfaction. I am aware 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 procedure or the exact degree of improvement I may achieve.

The planned procedure is ____________________________________

Dr. Van Camp has discussed in detail with me the information relating to this procedure that is briefly summarized below:

Please initial each item to confirm your agreement. (Print "NO" if you disagree.)

1. Nature and Purpose of Blepharoplasty
   
   Blepharoplasty is a surgical procedure by which excessive skin, associated muscle and/or fat present on the upper and/or lower lids is removed.
   Initial ____
   
   
2. Risks
   
   Expected side effects associated with eyelid surgery include soreness or discomfort, swelling, inflammation, bruising, numbness near the incisions, scars at the incision sites, skin pigment changes during healing, minor asymmetries or skin irregularities.
   
   I understand that there are other risks of eyelid surgery from both known and unknown causes. These may include infection, abnormal scarring, bleeding (including bleeding behind the eye that could rarely result in loss of vision), prolonged tearing, asymmetry of results, slight downward pulling of the lower lids or incomplete eye closure, or damage to other structures of the eye, nerves, or muscles. Some of these, were they to occur, may require further treatment by Dr. Van Camp or by other specialists.
   Initial ____
   
   I recognize that during the course of the operation, unforeseen conditions may necessitate additional or different procedures than those set forth above. I therefore further authorize and request that the above-named surgeon, his or her assistants, or his or her designees perform such procedures as are, in their professional judgment, necessary and desirable.
   Initial ____
   
   
3. Anesthesia
   
   I understand that either local anesthesia is required when eyelid surgery is performed, and that local anesthesia alone or with intravenous and/or oral sedation will be used. I consent to and request the administration of local anesthesia and systemic sedation by or under the supervision of Dr. Van Camp and his staff.
   
   I am aware that risks are involved with the administration of any type of anesthesia and sedation, including, but not limited to: allergic or toxic reactions to medications, respiratory depression and cardiac arrest.
   Initial ____
   
   
4. Alternatives to Blepharoplasty
   
   Alternatives, including no treatment, have been explained to my satisfaction. There are other methods to remove or tighten the excessive skin including laser resurfacing or chemical peeling which can improve the wrinkles present in the eyelid skin.
   Initial ____
   
   
5. Informed Consent
   
   I have had sufficient opportunity to discuss my condition and proposed surgery with Dr. Van Camp and all of my questions have been answered to my satisfaction. I believe I have adequate knowledge on which to give an informed consent for the proposed treatment.
   Initial ____
   
   
6. Photographs
   
   I consent to be photographed or videotaped before, during, and after the treatment, and that these photographs shall be the property of the above doctor and may be published in scientific journals and/or shown for scientific/educational reasons without identifying information. I understand that these images will not otherwise be used for commercial purposes unless I give a separate consent.
   Initial ____
   
   
7. Cooperation
   
   I agree to keep Dr. Van Camp and his staff informed of any change in my permanent address, and I agree to cooperate with the recommended for pre-surgical care, medication limitations, and aftercare instructions and follow-up visits. I understand that adhering to the recommendations for pre and after care are essential.
   Initial ____

The quoted surgical fee remains valid provided that 1) surgery is scheduled and the deposit is paid within 4 months of the date the quote was made, 2) the surgery is done within one year of the quote, and 3) the patient’s weight does not increase excessively after the time of the quote. The balance of the fee must be paid at least 14 days before surgery. There is no charge for routine follow-up care after the surgery. However, in the unlikely event of complications, the patient is responsible for fees charged by other physicians or hospitals. In the event of a secondary procedure to correct an unsatisfactory result, the surgical fee will be no more than 50% of the initial fee. There will be no additional charge for routine aftercare or management of any complications by Dr. Van Camp.

Paul Van Camp MD and staff have explained the nature, purpose, possible alternative methods of treatment, the risks involved, and possible complications associated with eyelid surgery. I acknowledge that no guarantee has been made as to the results that will be achieved. I agree to have any dispute or issue of medical malpractice decided by neutral arbitration rather than by jury or court trial. I understand that cosmetic surgery should not be done if a woman patient is pregnant; I have no reason to suspect that I might be pregnant.

I have carefully read all pages of this document, including the preoperative medication limitations and postoperative care instructions, and explanation of known risks. All of my questions have been answered to my satisfaction. I hereby request and give authorization to the above surgery.

Patient Signature__________________ Date __/__/__

Witness Signature__________________ Date __/__/__

Plausible risks have been discussed, all pages of this document were reviewed, and all of patients questions have been answered.

Physician Signature__________________ Date __/__/__