Summary of Consent form, to be signed at least 15 days before the procedure :
The main risks and complications of any operation are (this list is not complete):
infection, seroma (= a fluid collection), nerve damage (insensitivity of the wound, lesion of the facial nerve , … ) ,bruising, pain, hematoma (=bleeding), bad (stretched / thick / red/ raised / uneven / puckered ) scars, wound breakdown, delayed wound healing, allergic reactions, deep venous thrombosis of the legs, contour irregularity , asymmetry, implant failure , overcorrection, undercorrection, recurrence of sagging after lifting, result not matching expectations, …..
- It is recommended to inform your GP / family doctor ( and your next of kin ) beforehand and discuss your medication with him.
- I am 18 years old or older.
- In case of urgent follow-up treatment or secondary , complementary procedures only can be done in Belgium.
- Pre- and postoperative pictures will be taken and stored in the medical file.
I (the patient ) understand this operation is an elective cosmetic procedure and hereby acknowledge the following :
- That this procedure is performed for cosmetic reasons and because of this, the results can only be assessed subjectively. Therefore, I understand that while I have been advised as to the probable result, this should in no way be interpreted as a guarantee. No explicit guarantees have been made to me concerning the results of this procedure. In some situations, it may not be possible to achieve optimal results with a single surgical procedure.
- This contract shall be governed by the laws of Belgium. Conflicts or claims of contractual and/or extra-contractual nature about any aspect of the provided care, treatment or conduct shall be governed by the laws of Belgium. In case of conflict or claim of contractual and/or extra-contractual nature about any aspect of the care, treatment or conduct only the Belgian courts of East Flanders section Dendermonde / Antwerpen and the Belgian equivalent of the general medical council/GMC (‘ordre des medecins / orde van geneesheren’ in Belgium) are competent
- A package contract for travel and hotel has never been offered by the clinic or surgeon. The patient must book his/her travel and hotel independantly, having a free choice of how and where to book.
If the result is not matching the expectations :
This can happen after any type of cosmetic surgery.
- Additional procedure : in the event of any additional tuck-up surgery taking place for whatever reason then although the surgeons fee is waived in these circumstances, the patient will be responsible for travel and hotel costs and any anaesthesiologist or theatre facility fee ( see above). The fees charged for the current procedure do not include any potential future costs for additional procedures that the patient elects to have or require in order to revise, optimize, or complete his outcome
Consent form anaesthesia: I acknowledge that the anaesthetist or his nurse has reviewed the proposed anaesthetic with me and answered my questions. I request the use of anaesthetics for the relief and protection from pain during the planned and additional procedures. I realise the anaesthesia may have to be changed possibly without explanation to me. I understand that side-effects and complications may occasionally result, such as
- drug reactions(e.g. allergy , local anaesthetic toxicity , ….),
- respiratory ( airway blockage , lung and heart problems , like arrythmia , …. ) ,
- recovery problems ( low oxygen saturation in the blood , confusion, dizziness, muscle aching, nausea and memory loss, cognitive impairment, fatigue, ….)
- and although extremely unlikely, death(1:250,000).
- If an oral or nasal tube has been used : injury and pain at : throat, vocal cords, teeth.
- Due to immobilization on the table : blood clots in the legs ( which may block the lungs …. Thrombosis / embolism)
- Due to positioning on the table : pressure on nerves ( esp arms ( elbow nerve ) and legs , shoulder joints, buttock muscles ( sores ) , neck pain ( esp if already if stiff neck beforehand )
- Malignant hyperthermia ( very rare condition where the body is overheating )
You must inform the anaesthetist regarding any previous dental work or loose teeth, any heart or lung problems, problems in neck , back or shoulders, and problems related to anesthesia of family members, so that he can be extra careful.
Under no circumstances will your data be sold or ceded to third parties and will be
securely stored in an encrypted database.
So what will your data be used for?
– To contact you by email, text message, telephone or regular mail
– To send you a reminder of your next appointment
– To reschedule an appointment
– General processing only in function of our internal files
– To send you email newsletters
You have the right to have your data modified or deleted at any time. This
can be done by a simple email to firstname.lastname@example.org
Agreement with a general hospital
Singelberg Clinic has an agreement with the general hospital of Bornem ( www.azr.be ) for secondary transport of patients should this be necessary.
If the patient is not satisfied with the treatment, they can initially contact the treating physician himself, preferably by email ( email@example.com ) and / or the closest colleague – physician in the Singelberg Clinic. If this is insufficient, then the patient is referred to a third doctor, independent of the Singelberg Clinic, in consultation. Finally, the mediation service ( ombudsman ) of the hospital in Bornem ( www.azr.be ) can also be contacted @ firstname.lastname@example.org