Dr.
Bernard CORNETTE DE SAINT-CYR
15, rue Spontini,
75116 PARIS-FRANCE
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FRENCH NATIONAL MEDICAL ASSOCIATION REGISTRATION:
No 75-33122
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Surgeon qualified in:
RECONSTRUCTIVE PLASTIC AND COSMETIC SURGERY
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MUTUAL INFORMED CONSENT
I, undersigned, last name and first name,
born on ………….., request and authorize
Dr. Bernard Cornette de Saint-Cyr,
his team, as well as other health professionals
deemed necessary, to carry on my person:
– the following act of cosmetic surgery:
…………………………………………….
– date of the operation:
on………………………………………….
– under anesthesia
…………………………………………….
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During consultations with Dr. Bernard Cornette de Saint-Cyr,
Date of first consultation: …………………………
Ate of second consultation: ………………………
I have informed Dr. Cornette de Saint-Cyr about all care, procedures, treatments and medications that I’ve undergone and taken to date, as well as of their possible complications.
I was been informed of the expected benefits of this procedure, its dangers and limitations, and of therapeutic alternatives as well as of the possibility of relapse.
The location of the incisions and the evolution of scars – which varies depending on patients – the outcome of surgery as well as normal or complicated consequences of the operation or anesthesia have been explained to me. The doctor, in particular, stated that this procedure, although practiced for several years with very satisfactory results can, in some cases, present unforeseen complications and that no result can be guaranteed.
A written information sheet on the procedure was given to me and commented at the occasion of the first consultation. (Strike out if not present)
I understand that there are risks (bleeding, infection, allergic reaction, healing disorders, etc.) associated with the procedure, as with any surgery, and that these can be serious or life-threatening.
I was also warned that during the procedure, the surgeon may be faced with a discovery or an unforeseen event imposing additional or different actions of those originally planned and I already authorize Dr. Bernard Cornette de Saint-Cyr, under these conditions, to take any action deemed necessary or to be assisted in the matter by another practitioner.
I confirm that the explanations and answers to questions were in sufficiently clear terms to allow me to make my choice and ask the Dr. Bernard Cornette de Saint-Cyr to carry on with the realization of this procedure.
I acknowledge that the reflection period between the first consultation and the date of the procedure is quite sufficient.
Done at Paris, ………………………..
Signature:
(preceded by the mention “read and approved”)
