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Topic 32 - 2
Informed Consent
for Blepharoplasty Surgery
instructions before blepharoplasty Experiencing experiencing blepharoplasty


This consent form is for general informational purposes only. Your doctor's form will differ.

Before your treatment
(either the morning of or sometimes a few days ahead of time), you will asked to read and sign a form granting permission for the surgeon and staff to perform your blepharoplasty. This surgical "informed consent" is an important legal document that should not be treated as a mere formality.

1. I, _______________________, authorize Dr. _________ to perform on me an operation known as blepharoplasty, also known as eyelid lift. This procedure is undertaken for the sole purpose of attempting to remove or reposition excess skin, fat and/or muscle from the eyelids to improve my appearance and/or improve my peripheral vision.

Blepharoplasty surgery will be performed on:

(Circle one)
Both upper eyelids
Both lower eyelids
All four eyelids
One eyelid ______

Treatment will be delivered in the:

(Circle one)
Office operating room

2. The nature and purpose of blepharoplasty surgery have been explained to me as well as any feasible alternatives, including having no surgery at all. I understand that my doctor will attempt to improve my appearance and/or peripheral vision by removing skin and/or fat and/or muscle tissue from my eyelids. Droopiness caused by forehead or brow relaxation or defective support within the deeper eyelid tissue will not be improved by this operation. I understand that blepharoplasty surgery gives a relatively long lasting result, but I have not been promised any permanent correction from the progressive changes of aging.

3. I consent to the administration of anesthetics or sedative medications, which will be given orally, by injection into the tissue, by injection into a vein, or by inhalation.

4. I consent to the performance of any other additional medical or surgical procedures that my doctor feels are medically necessary during the course of my operation if arising due to unforeseen circumstances or complications during the operation.

5. I know that the practice of medicine and surgery is not an exact science and that reputable practitioners cannot guarantee results. No guarantee or assurance has been given by anyone as to the results that may be obtained.

6. All medical and surgical treatment carries with it the possibility of adverse reactions and complications. The following list of potential complications is not intended to scare you but rather inform you of the major possible adverse reactions that could occur from surgery on the eyelids.

I understand the major risks and complications of blepharoplasty surgery to include the following:

From anesthesia: Serious heart or breathing problems, drug reactions, allergy

From surgery: Infection, excessive bleeding, loss of vision, double vision, inability to close the eyelids fully, droopy upper eyelids, retracted lower eyelids, poor cosmetic result, over-correction, under-correction, scarring, tearing, the need for additional surgery.

7. I consent to the photographing of my appearance before, during, and after the surgery for medical documentation and/or insurance-related purposes.

8. I consent to the disposal of any tissues removed surgically.

9. I have been advised of the nature of the proposed surgery and anesthesia to my satisfaction. If I desire any additional explanation of the foregoing or further information about the operation and its risks and possible complications, this has been given to me prior to the signing of this surgical consent.

Signed _____________________________

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