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Consent form

CONSENT FORM
Tel (Res): ., Mobile : ., Tel of friend /parents: .
Email: . have been advised under go hair transplantation I also state that I have understood the following address.
I have understood male hormones mediate the baldness that I have.
I am aware of that hair transplantation is only a cosmetic procedure and have been involved in decision of making about the choice of treatment.
I understand that while every effort will be made by the operating doctors to ensure optimum result a number of variable do exists and hence optimum results cannot always be guaranteed.
I have been explained that I will not have and cannot expect that I will have a full head after surgery. I understand that transplants are not perfect.
I am aware that the procedure will be performed under local anesthesia and give consent for the same.
I have been explained and understood the procedure of the surgery as follows: a) The posterior scalp will serve as the donor area. A strip of skin will be removed and sutured: understand that
there will be a scar in this area.
b) The hairs from the donor area will be dissected and implanted on the bald area using special instruments.
c) I have been explained about the possible complications that may occur during and after the procedure:
I) Postoperative swelling of forehead on 3-5 days. iii) Pustules/boils/pimple like lesions in 2-3 month I have also been explained that keloids, complication in any surgery, may occur after transplants.
d) I have been shown chart/brochure about the procedure and hair loss, which I have understood.
I am aware that after the procedure, there may be a period of temporary hair loss. And that it may take 9-10 months after surgery for proper hair growth.
I have been explained that I may need ___ of operations for optimum cosmetic results. I am aware that good results will depend upon the necessary number of operation sessions to be undergone.
I am aware that the process of baldness may continue after the surgery in other areas of the scalp, I have fully
understood the above information after reading it/being transplanted the same by Dr.
I hereby give consent for Dr. Venkataram to perform the procedure and any other medical service that may
become necessary during the procedure.
The consent form has been signed by when I was not under the influence to any drugs.
4. Did you have any injury/wound, which was sutured? If so was there a problem? 5. Did you have any problem with bleeding? 10. Do you have diabetes/asthma/any other disease? 11. Have you recently taken injection tetanous toxoid in last 6 months? 12. Do you faint when seeing blood? Are you nervous person? 13. Will you able to come for stitch removal after 12 days? 14. Are you Allergic to any Medicine? If so, mention it 15. Do you take drugs for any other problem?If so mention it.
16. Have you received pre-op, post-op instruction sheet? Please Note: Date once booked cannot be changed except for emergencies and unless informed 2 weeks prior to the date of surgery, otherwise advance will be forfeited.
HAIR TRANSPLANTATAION: INSTRUCTION FOR PATIENTS after booking.
1. Make sure you have obtained all the information you need; visit our web site www.bangalorehairtransplant.com us on 080-23392788/23392416/41148848/9845363520 or visit us for any clarification.
2. The following Blood Tests need to be done before surgery: Hb%, BT, CT, RBS, LFT, HbSAg, HIV-ELISA and ECG in all leads: these are simple and routine tests which may be done in any lab. It can be done with us also. Show the results to doctor prior to the surgery.
3. We need an advance payment of Rs. 10000/- to book the surgery, either by card/cash/cheque/online transfer. Balance full payment to be paid before surgery either by cash/card only. If you wish to make online transfer , please ask for our account number.
4. You will have to sign a consent form before surgery.
5. If you need hotel accommodation, it can be arranged by our staff.
6. Any change in date, once booked, can be done only if informed well in advance (14 days). Last minute request for change of date may result in forfeiting the advance.
Pre operative instructions:
1. if you have dandruff, use KZ/Arcolane/Scalpe Shampoo daily for 3 days before surgery.
2. If you have any Medical Problems inform the doctor; do not take any drugs before surgery without informing the doctor.
3. Relax; avoid exertion the day before surgery.
4. Take easily digestible food: Dal, Rice, Rasam, Sambar and vegetables-avoid spicy food.
5. Avoid smoking/Alcohol, for a week before surgery.
On the day of surgery:
1. Reach the centre by the time informed to you; do not be late.
2. IMPORTANT: Do not come on empty stomach. COME ON A FULL STOMACH. Have lunch/breakfast depending on the time of arrival.
3. Wear comfortable loose fitting pant and shirt with buttons, don’t wear t-shirt.
4. Don’t bring any valuable things (gold items) in your bags/ shirt to the clinic, if you have handed over to nurse for safe custody.
5. You may bring any VCD/DVD of your choice to watch during the surgery.
6. Surgery will take about 3-5 hours.
7. You may travel back in auto/car/taxi but not on two wheeler; you cannot drive after surgery when you go back to home, nor can sit on pillion; if you wish to go by city taxi, ask at our front office.
After going back:
Please note that hair transplantation is a very predictable surgery; all postoperative events are already informed to you, so there is no need for any anxiety.
1. Have light food, Rice, Dal, Chapatti, Rasam and non spicy food.Dont drink alcohol or smoke 2. Take medicines as per the prescription. All capsules to be taken after food or glass of milk-not in empty stomach. Remember that Proxyvon capsule is for pain. It acts about 4-6 hours- so you may need one more capsules at night. Do not hesitate to take one it if needed. But take it after milk/food.
7. Use soft pillows. You may lay on the back of head.
8. If you feel pain take 1 additional cap of Proxyvon, but with a glass of milk.
If there is any urgent problem beyond what is already mentioned, you may contact us on 23392788/23392416 after 8.00 pm ONLY if urgent call on 9845363520.
you may go to office if you feel like, Avoid exertion. We have put a pink plaster on your forehead to prevent swelling. This should be in place for DO NOT REMOVE THIS.
After removal of bandage: Note that moisture is very important for grafts; So wet the hairs both in donor and
recipient( grafts) either by spray or wet pad of water; don’t be hesitant to put water; water should be clean;
mineral water or boiled cooled water; you may add a small pinch of salt to the water. Do wetting as often as
you can( 2-6 times) for the first 4 days. Dont disturb the grafts by rubbing / combing. Rest of the scalp may be
cleaned by baby shampoo if you wish; otherwise water is enough
Postoperative swelling :
This may appear in 5% of patients on the fore head which may come down to eyelids on day 4/5. If so do not worry, it will disappear in ½ day. Apply ice cubes as follows.
b. Keep them in piece of cloth. If you do not have ice, take wet cloth in clod water.
c. Keep the ice pack o the swollen area for 2*3 minutes for 4-5 times for 2 days.
d. You have been put a pink plaster on forehead. This is to prevent swelling. Let it remain for 3 days.
Sutures:
Sutures can be removed any time after 10days by our nurse, this is a simple painless procedure taking about 10 minutes. For those who are from outside Bangalore, absorbable sutures are put and these will be absorbed by 2 weeks. Hairs may start falling by 2 weeks. Do not panics- the roots are firmly in place. Some times, you may see whitish material sticking on to roots; don’t worry about it.They will start growing by 3-4 month; you will see full results in 9 months. Apply Minoxidil lotion twice a day 1ml and take tablet Finpecia after 1 week for one year. Minoxidil may cause some dryness/dandruff ; use a conditioner called Triflow or pantene.
NOTE:Some patients are too anxious to clean grafts; so they may see grafts with greenish brown material
sticking to skin; this only needs proper cleaning. Note that after 7 days, rubbing is allowed.
Do send your photos to our clinic on [email protected] or [email protected] Any time you have doubts contact us by email or telephone if urgent After 9 months:
ENJOY YOUR NEW LOOK AND BE HAPPY !!

Source: http://bangalorehairtransplant.in/consent_form.pdf

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