COSMETIC SURGERY CONSENT

COSMETIC SURGERY CONSENT

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Patient’s information
Full Name: Date of birth: Gender:

Address: Phone: Email:

Nationality: Proposed procedure (intended
treatment or surgery):

Allergies:

Any special requests (e.g. translation)
______________________________________________________________________________

Patient’s Contact Person
Name: Phone: Relationship to Patient:

Patient’s External Physician
Name: Contacts (Phone and Email): Facility name:

Services List
1) Eye- Blepharoplasty

☐Upper Blepharoplasty
 Blepharoplasty of the upper eyelids is a plastic surgery that
consists of removing excess skin and fat deposits in the
periorbital region.
 20 minutes surgery time.
 General Anesthesia
 3-5 days Recovery Time
 Day Care-Hospital Stay

☐Lower Blepharoplasty
 Lower transconjunctival blepharoplasty is aplastic surgery
aimed at removing the fat pads of the lower eyelids.
 20 minutes surgery time.
 General Anaesthesia
 3-5 days Recovery Time
 Day Care-Hospital Stay

☐Look of Cleopatra
 This is an aesthetic surgery aimed to elevate the drooping
outer corner of the eye. After this procedure, the look
becomes more open and visually bigger.
 20 minutes surgery time.
 General Anaesthesia
 3-5 days Recovery Time
 Day Care-Hospital Stay

☐ Browlifting
 This is an aesthetic operation that allows raising the outer
corner of the eyebrows. Note that this procedure doesn’t
require incisions.
 30 minutes surgery time
 General Anaesthesia
 3-5 days Recovery Time
 Day Care-Hospital Stay

2) Nose- Rhinoplasty

☐Closed Rhinoplasty
 This is a more complex operation than
Open Rhinoplasty, but a minimally
invasive, more aesthetic result is achieved
without stitches on the outer part of the
nose. The result of Closed Rhinoplasty is
changes in nose size, nostrils and correct
nose symmetry, as well as a faster
recovery period (compared to Open
Rhinoplasty).
 1 hour surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐Septoplasty
 This is an operation to eliminate
nasal septum curvature and to
improve breathing.
 20 minutes surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐Rhinoplasty Revision
 Secondary Rhinoplasty
 1.5-5 hours of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

3) Breast- Mammoplasty

☐ Periareolar Lift
 This is plastic surgery of areola breast lift
 30- 40 minutes of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐ Vertical Lift
 This is a breast lift plastic surgery in which vertical
incisions are made from the areola to the inframammary
fold.
 1-2 hours of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐ Anchor Breast Lift
 Anchor breast lift is a plastic surgery in which a continuous
incision is made around the areola down and parallel to the
sub mammary fold.
 1-2 hours of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐ Mammoplasty
 This is an operation aimed at correcting the shape,
position, and volume of milk glands.
 15-30 minutes of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

4) Men
☐ Pectoral Implants
 The suture is made in the axillary region (armpit) the length
of the suture is 3-4 cm, depending on the breast implant (12
months after the operation the suture will not be visible
 About 45 minutes of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐ Gynecomastia
 This is a pathological condition of milk glands, which is
characterised by an increase in their size. With the help
of this procedure, you can get rid of the excess of both
glandular and fatty tissue
 About 45 minutes of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

5) Face- Lipofilling of the Face

☐ Frontal Lipofilling
 It has survived not only five centuries, but also the leap into
electronic typesetting, remaining essentially unchanged. It
was popularised in the 1960s with the release of Letraset
sheets containing Lorem Ipsum.
 About 40-50 minutes of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐ Eyebrow Lipofilling
 Surgical procedure aimed at producing an eyebrow lift.
 About 30 minutes of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐ Temporal Lipofilling
 Surgical procedure aimed at making the temples of the face
fuller.
 About 30 minutes of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐Lipofilling Nosolacrimalis
 Surgical procedure aimed at making corners of the eyes
firmer.
 About 30 minutes of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐ Zygomatic Lipofilling
 Surgical procedure with the intent of increasing the volume
or changing the shape of the cheekbones through the
infiltration of autologous fat or better yet from the same
patient.
 About 1 hour of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐ Correction of the Nasolabial
 Surgical correction restoring the lost volume and
softening the appearance of these creases.
 About 1 hour of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐ Remove fat near the lips
 Surgical procedure to remove buccal fat around the areas of
the cheek, and not the corner of the lips.
 About 30-45 minutes of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐ Correction Nosollabialis
• Nasolabial folds are the indentation lines on either side of
the mouth that extend from the edge of the nose to the mouth’s
outer corners. They become more prominent when people smile.
This surgical procedure helps restore them.
• About 30 minutes of surgery time
• General Anaesthesia
• 1-2 weeks Recovery Time
• 1 day hospital stay

☐ Lipofilling near Ear Wrinkle Area
 Surgical procedure aimed at ear lobule rejuvenation with
ear lobule ptosis and deflation which are characteristics of
facial aging.
 About 30 minutes of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐ Lipofilling Horizontal Jaw Line
 Surgical procedure that helps to harmonize square, round
or long faces and thus obtain a vertical-horizontal
balance of the face.
 About 30 minutes of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐ Lips Lipofilling
 Surgical procedure that adds volume to thinning lips,
creating a more youthful appearance.
 About 1 hour of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐ Venus Ring Removal
 This is a correction of lines and folds on the neck.
 2-2.5 hours of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐ Mentoplasty
 This is a chin reshaping surgery that aims to enlarge the
chin and reshape its contour in order to make the face more
symmetrical and to improve its profile.

☐ Otoplasty
 Otoplasty is an ear correction surgery aimed at correcting
the auricles to improve the appearance of the ears to
varying degrees. It can address concerns with your ears’

 About 2 hours of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

size, shape, positioning, or proportion.
 About 2 hours of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

6) Body- Liposculpture
☐Sports Liposuction + Lipofilling of Buttocks
 surgical procedure aimed at removing excess fat from
unwanted areas of the body to obtain an aesthetic result..
 About 2 hours of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐Liposuction Arms, Underarms
 a quick way to remove excess fat for those who have a lot
of excess fat in the arm and armpit area
 About 30 minutes of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐Sports (Abdomen, Lower Back)
 a quick way to remove excess fat for those who have a
lot of excess fat in the lower back and abdomen area
 About 1-2 hours of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐Pubic Liposuction
 a quick way to remove excess fat for those who have a lot
of excess fat in the groin area.
 About 20 minutes of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐Secondary Liposuction
 a quick way to remove excess fat for those who have a
lot of excess fat and give an aesthetically pleasing
appearance.
 About 3-4 hours of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐Inner Thighs
 a quick way to remove excess fat for those who have a lot
of excess fat in the inner thigh area.
 About 30-45 minutes of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐Outer Thighs
 a quick way to remove excess fat for those who have a
lot of excess fat in the outer thigh area.
 About 30-45 minutes of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐Knees
 a quick way to remove excess fat for those who have a lot
of excess fat in the knee area.
 About 15 minutes of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

Implants
☐Gluteoplasty
 Plastic surgery the task of which is to correct the volume
and buttocks’ contour with the help of implants.
 About 1 hour of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay
☐Cruroplasty
 This is the correction of the legs’ contour with the help of
implants
 About 45 minutes of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

Body Modelling
☐Belly Button Correction
 Surgical Procedure that changes the appearance of your
bellybutton.
 About 30 minutes of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay
☐ Brachyloplasty
 This is the correction of the hand’s contours with the help
of an operation to remove sagging skin and fat from the
inside of the upper arm. After the procedure, the hands
acquire beautiful outlines, both from behind and from the
front.
 About 40 minutes of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

☐Caesarian Scar Removal
 Surgical Procedure that removes scars from previous
caesarian section
 About 1 hour of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay
☐Skin tightening of Legs
 Surgical Procedure to remove sagging skin and fat from the
legs and thighs.
 About 2.5 hours of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay
☐Knee Rejuvenation
 This is an aesthetic procedure after it skin becomes more
elastic, and the degree of wrinkling and flabbiness in the
knee area is reduced. There is no stitches in this procedure.
 About 45 minutes of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

Abdominoplasty
☐Complex Sports Liposuction
 Surgical method for removing fat and excess skin in the
abdomen, which allows for achieving more aesthetic
body contours. The purpose of the procedure is to
remove excess fat and tighten skin.
 About 3-4 hours of surgery time
 General Anaesthesia
 1-2 weeks Recovery Time
 1 day hospital stay

Pricing. The procedure for _______________will cost an AED ________________USD_____________. Please
note that the aforementioned price includes:
– The Procedure
– 1 day admission
– General or Local Anesthesia
– Meals
– Medicine
Note:
-Additional stay will cost AED 2500/day
-Pre-Operation Tests will cost an extra AED 2000
Please note:
The cost does not cover:
-Future visits to the doctor
-Correction surgeries
-Costs associated with any clearance evaluation needed prior to surgery
-Costs for a Specialist Consultant
-Medicine for an underlying problem
-Treatment for an underlying or connected conditions or complications arising from surgery

Expectations. A person’s overall appearance can be enhanced through the use of cosmetic surgery but
one’s expectations should be realistic to avoid disappointments. Having the wrong expectations or having
overly optimistic expectations might result in being let down. Having a realistic outlook leads about
feelings of contentment. In addition, the outcomes are variable for each individual.
Complications. Some of the common complications are: bruising, swelling, bleeding/ haematoma,
seroma, loss of sensation, numbness, infection, issues with the way wounds heal, DVT/PE, scarring
issues (risk hypertrophy and keloid), chest infection, general asymmetry, pain and discomfort. Different
people’s responses to the same procedure might vary greatly. This list is not exhaustive and just includes
risks that are frequently encountered. Additional hazards have been shared by the Surgeon to the Patient.
Smoking. It is well-known that smoking increases a person’s risk of post-surgical wound healing issues,
which in turn increases the chance of infection, operative and postoperative bleeding, and scarring. The
Patient needs to let the Surgeon know if they smoke because the Surgeon may want the Patient to quit
smoking for a certain amount of time. Smoking can negative impact aftercare.

Surgeon’s declarations
The procedure will be undertaken by _____________________________ (Surgeon’s name)
 I am duly authorized, and qualified to perform the subject procedure.
 I have provided the patient with an explanation of the procedure, given them adequate time to
process the information provided, and ask questions to their satisfaction.
 I have talked about the restrictions that come with cosmetic surgery, as well as issues relating to
expectations and the importance of being realistic about one’s own aspirations, as well as the fact
that outcomes are not guaranteed.
 I have also gone over what the procedure is likely to entail, the postoperative period, risks and
complications associated with the procedure.
 I attest to the fact that I have described all the non-surgical treatment choices including no surgery
to the patient, the benefits and risks of any available alternative treatments and allowed them an
appropriate amount of time to inquire about them.
 I have provided a comprehensive consultation in accordance with my training and qualifications
and having looked at the patient’s family history.
 I have ascertained that the patient is in favor of undergoing the treatment.

Patient’s declarations
 I have provided true and accurate information herein and shall promptly notify the Surgeon of any
changes to the information already provided. I have fully and accurately told the Surgeon of my
whole medical history and status to the best of my knowledge and have done so to the best of my
ability. I am aware that keeping certain medical information to oneself may increase the risk of
experiencing difficulties or other issues that could have been avoided if those details had been
known in advance of my surgery. Inaccurate information regarding my medical history will result
in the nullification of this contract as well as any potential claims that I may have against the
Facility and Surgeon.

 I hereby give permission to the Surgeon, together with any assistants that may be chosen, to carry
out the procedure or treatment herein.
 I am aware that unanticipated circumstances may call for other procedures than those outlined
above when the subject operation is being performed, medical care is being administered, or
anesthetic is being administered. I thus give the aforementioned Surgeon permission, along with
any assistants or designees he or she may choose to work with, to carry out any additional
procedures that, in the Surgeon’s opinion, are necessary or desirable. The authority that has been
granted to the Surgeon herein covers any and all conditions that require treatment but are
unknown to him or her at the time that the procedure is started.
 I agree to have any and all anesthetics that may be deemed necessary or desirable to be
administered to me. I understand that every kind of anesthetic carries with it the potential for
adverse effects, including injury, illness, and even fatalities.
 I am satisfied with the Surgeon’s qualifications and experience.
 I am aware of the capabilities and limitations of my surgeon and am aware that there are no
promises or assurances, either express or implied, about the outcome of my procedure. The fact
that this treatment is carried out for cosmetic reasons, and as a consequence, the results can only
be evaluated subjectively, I am aware that even though I have been provided with information
regarding the likely outcome, this in no way should be construed as a guarantee of any kind
regarding the outcomes of this treatment. I am fully aware that it is possible that the outcome will
not meet either my expectations or the goals that may have been established by either myself or
the Surgeon.
 I have been given the chance to discuss my objectives and have gained an understanding of which
of my intended outcomes are feasible and which are not. My inquiries have all been addressed,
and I have an understanding of the inherent (particular) risks that are associated with the
procedures that I want, in addition to the additional risks and problems, advantages, and other
available options. Having considered everything, I have decided to move forward.
 I consent to being photographed or televised before, during, and after the operation(s) or
procedure(s) that are to be performed, including appropriate portions of my body, for the purposes
of medical research, scientific research, or educational research, provided that the pictures do not
reveal my identity.
 I give my permission for observers to be present in the operating room so that furthering medical
education can be accomplished thereby.
 I give my permission for any tissue, medical devices, or other elements of my body that may be
removed to be discarded.
 I am aware that the use of blood products may pose possible severe hazards to my health; yet, I
consent to the use of blood products in the event that they are considered essential by the Surgeon
and/or his/her appointees.
 I am aware that not undertaking the operation is a choice that can be made.
 I am also aware that any questions that I may have on the procedure should only be directed to the
Surgeon or other qualifies professional.
 I understand that the Facility shall not be liable for negligence or breach of contract based on the
Surgeon performing the procedure.
 I understand that it is my responsibility to follow the instructions that have been given to me by
the Surgeon before, during, and after the surgical procedure that has been described above. In
addition, I will promptly inform the Surgeon or Facility of any issues that may arise as a result of
my surgery failure to which this contract will be null and void, and I will be unable to pursue any
claims that I may have against the Facility or the Surgeon.
 I am aware that additional treatment might be required in order to achieve the desired results. This
in no way indicates that the procedure was performed negligently or below acceptable standards. I

will not make any claims based on the possibility that I will require additional treatment or
surgery.
 It has been explained it to me in a manner that I can grasp: WHAT THE PROPOSED
PROCEDURE OR TREATMENT CONSTITUTES, ALTERNATIVE PROCEDURES OR
METHODS OF TREATMENT MAY BE AVAILABLE, and THE PROPOSED PROCEDURE
OR TREATMENT HAS RISKS.
 I have taken my time in making my decision, having asked all my questions and being satisfied
with the responses given.

Post-Surgery. Always pay close attention to the directions given to you by the Surgeon; doing so
is absolutely necessary for the success of your outcome. During the period that the surgical
incisions are healing, it is critical that they not be exposed to an excessive amount of strain,
swelling, abrasion, or motion. This will ensure that the wounds heal properly. Activity in both
one’s personal life and one’s professional life needs to be controlled. Unless specifically ordered
to do so by your plastic surgeon, you should not remove any drains or protective dressings.
Both the operation and the care that follows it are necessary for the recovery of function after it.
When you engage in physical activity that raises your pulse or heart rate, you run the risk of
suffering from bruising, edema, fluid collection, and the requirement to undergo additional
surgery. After surgery, it is essential that you participate in follow-up care, return for aftercare,
and encourage your own recovery in order to avoid further complications.

I AGREE TO THE TERMS ABOVE AND THAT THE TREATMENT OR PROCEDURE,
SHOULD BE PERFORMED. I HAVE RECEIVED COMPLETE AND SUFFICIENT
EXPLANATION HEREIN. I ENTER INTO THIS AGREEMENT FREELY AND
VOLUNTARILY.
By signing, you agree to be bound by this agreement.

__________________________________ ______________
Patient’s Signature or Person Authorized to Sign for Patient Date

_____________________________ ______________________ ____________
Witness (name) Signature Date

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