INFORMED CONSENT FOR PLASTIC / COSMETIC SURGERY

You have the right, as the patient, to be fully informed about your condition and the recommended surgical, medical or diagnostic procedures including potential risks and side-effects so that you can make the decision as to whether or not to undergo the procedure.

It is a legal requirement that before any surgical operation, you read and sign a consent form. The purpose of this form is to confirm the specific procedure agreed upon and an understanding of the benefits, risks and side effects related to that procedure. It will also document any procedures or treatments you do not wish to receive.

  • I voluntarily request Mr Adrian Richards as my surgeon and such associates, technical assistants and other health care providers as deemed necessary, to carry out the following surgery
  • I understand that no warranty or guarantee has been made to me as to result or cure. It is possible that the result might not live up to the expectations or goals established. In this connection I am aware that the practice of surgery and medicine is not an exact science and those therefore reputable physicians cannot guarantee results.
  • I understand that any procedure in addition to those described on this form, will only be carried out if it necessary to save my life or to prevent serious harm to my health.
  • I realise that as in all medical treatments, complications or delay in recovery may occur which could lead to the need for additional treatment or surgery and could also result in economic loss to me because of my inability to return to normal activity as soon as anticipated.
  • I have been told about additional procedures, which may become necessary during my treatment. I have listed below any procedures which I do not wish to be carried out, without further discussion:
  • I confirm that I agree to the use of blood and blood products as may be necessary to save my life or to prevent serious harm to my health.
  • I understand that external incisions leave scars that are visible. The location of these incisions has been described to me. I also understand that it is impossible to predict the exact ultimate appearance of these scars. I have been advised that the scars can take up to 18 months to mature and the changes that normally occur in their appearance during the healing period, such as redness, lumpiness and irregularities have been described to me. I also understand that although unsightly scars can be surgically revised, this does not provide any guarantee that the subsequent appearance of the scar will be invisible.
  • I confirm that I have been given the information relating to the surgery that I am undertaking
  • I confirm that I have been informed of the risks and side effects related to the performance of the surgical procedures planned for me. I understand that common to most surgical procedures, is the potential for infection, swelling, bruising, bleeding, blood clots in veins and lungs and allergic reactions. I also realise that the following risks and side effects may occur in connection with this procedure.some text
    • Unsatisfactory appearance
    • Unattractive scarring                                                                                                                                              
    • Poor Healing
    • Skin loss
    • Nerve damage with associated sensory changes or prolonged pain and discomfort
    • Seroma
    • Changes in Appearance in time and with weight change or pregnancy
    • Reduced Nipple Sensation
    • Necrosis of the skin or nipple
    • Asymmetry
    • Stretch marks
    • Symmastia
    • The need for revision surgery in some cases
  • I confirm that I have read the Patient Guide on my surgery.
  • I understand that any pre-existing chest asymmetry or abnormality will not be improved with surgery
  • I understand that any pre-existing abnormalities in my nipple appearance or position will remain following surgery.
  • I confirm that I have been told about the following additional risks and side-effects that may occur in connection with the following procedures:
  • THIS PARAGRAPH PERTAINS TO SMOKERS: Smoking will affect the outcome of your surgery. There is a significantly higher risk of post-operative pneumonia, wound infections and delayed healing, as well as operative and post-operative bleeding. Some procedures are high risk and my surgeon will not operate unless you have agreed to stop smoking for 2 weeks prior to your surgery. I recommend that you refrain from smoking for 2 weeks following your surgery or until all wounds have healed satisfactorily. For other procedures, where the tissue is less vulnerable if you cannot stop at least try to cut down. If you need assistance stopping, I would be happy to advise you or you could see your General Practitioner.
  • ANAESTHESIA: I acknowledge that the anaesthetist has reviewed the proposed anaesthetic and answered my questions in this regard. I understand that anaesthesia involves additional risks and side effects but I request the use of such anaesthetic for the relief and protection from pain during the planned and additional procedures. I realise that the anaesthetic technique may have to be changed, possibly without explanation to me. I am aware that modern anaesthesia is very safe but certain complications may arise such as drug reactions, respiratory and (rarely) recovery problems, minor throat discomfort (temporary) as well as injury to vocal cords and teeth (very rare).
    Please inform your anaesthetist about any previous dental work, prior anaesthetic and your relevant medical details.
  • THIS PARAGRAPH PERTAINS TO FEMALE PATIENTS ONLY: Anaesthetic agents can be harmful to the foetus of a pregnant woman. General anaesthesia should be avoided during pregnancy, whenever possible. I hereby state that I am not pregnant and accept the responsibility for making this determination.
  • PHOTOGRAPHS AND/OR VIDEO RECORDING: I confirm that I agree that Mr Richards or any assistant he designates may take such photographs and videos as required for diagnostic purposes and to enhance the medical records. I agree that these photographs and videos will remain the property of Mr Richards.
  • I confirm that /have fully informed Mr Adrian Richards correctly and to the best of my knowledge, of my full medical history and status. I understand that withholding medical information could lead to complications or problems that may have been prevented if that information were known prior to my surgery.
  • I confirm that Mr Adrian Richards has discussed the operation with me to my satisfaction, this consent form fully explained to me and that I have read or had it read to me, and that I understand its content.
  • I confirm that/ have been given the opportunity to ask questions about my condition, alternative forms of anaesthesia and treatment, risks of non-treatment, the procedures to be used and the risks and side effects involved and I believe that I have had sufficient information to give this informed consent.
  • I have read the Patient Guide booklet and any other information provided by Mr Adrian Richards prior to surgery, discussing the operation and potential complications.
  • I have been shown pre and post-operative photos of patients who have undergone similar surgery.
  • I agree to follow the instructions given to me by Mr Adrian Richards, his associates or health care providers to the best of-my ability before, during and after the above mentioned surgical procedure and will notify Mr Richards of any problem following my surgery.

2025 © iQONICAESTHETICS

T&C

iQonic Aesthetics Ltd is an Appointed Representative of Chrysalis Finance Limited, which is authorised and regulated by the Financial Conduct Authority. iQonic Aesthetics is a credit broker, not a lender. The provider of a payment scheme that is not offered through or by Chrysalis Finance Limited may not be so authorised and regulated.