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Sample consent form

Article-Sample consent form

GREG S. MORGANROTH, M.D.
FELLOWSHIP-TRAINED DERMATOLOGIC SURGEON
525 SOUTH DRIVE, SUITE 115
MOUNTAIN VIEW, CA. 94040
(650) 969-5600

FACIAL LIPO-LIFT PROCEDURE PHYSICIAN CHECKLIST

— Reviewed my training as a Mohs and dermatologic surgeon and daily practice

— Reviewed history and evolution of the Lipo-Lift procedure

— Reviewed surgical technique and post-operative issues

— Discussed technical differences from the traditional facelift

— Discussed other surgeons' criticisms of the local anesthesia procedure and non-plastic surgeons performing cosmetic procedures

— Disclosed number of cases performed up to this time as well as any complications

— Provided pre- and post-op photos of prior patients demonstrating range of results

— Discussed importance of patient post-op follow-up for at least 1 year

— Discussed early post-operative healing has swelling, numbness, skin irregularity, bruising, and variable healing of the incision that may last for months. Patients need to follow up per Dr. Morganroth's recommendations to ensure proper healing and management of any issues

— Discussed the most prevalent post-operative issue has been delayed healing of the incision or the skin around the incision

— Discussed duration of healing period is at least 1 year

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GREG S. MORGANROTH, M.D.

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PATIENT SIGNATURE

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COSMETIC CONSULTANT/NURSE

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PATIENT NAME

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DATE

A sample of Dr. Morganroth's cosmetic procedure-specific consent form checklist. As he completes his verbal review of the checklist Dr. Morganroth hashis patients initial each statement as a record that the step has been discussed.

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