I, _________________________________________ holder of the identity card No. _________________, authorize Dr (a). Luisa Elena Fariñas Ramirez Haake , (Surgeon Plastic, Reconstructive and Maxillofacial), and their surgical medical equipment, to be me (n) practiced (s) the (or) following (s) treatment (s) in my person (or the person dependent child ___________________________________): ________________ _________________________________________________________ _________________________________________________________ authorize also for the realization of all or any medical or surgical procedure to judge him or his need to obtain better results in treating medical equipment (s) clinical (s) or surgical (s) previously explained (s) as well as the application of any investigative resource, laboratory and therapeutic necessary and indispensable criterion Dr (a). Luisa Elena Ramirez Fariñas Haake , and his team, for greater safety and better results of this (os) treatment (s), or to clarify any intercurrences or complications. This authorization extends to other (s) doctor (s) request (s) by Dr (a). Luisa Elena Ramirez Fariñas Haake , and your medical team, participating in the conduct of this (these) treatment (s) or investigation (s). To confirm and strengthen this authorization, I declare I have previously received from the Dr (a). Luisa Elena Ramirez Fariñas Haake , all information about (the) treatment (s) will be subject to (a) and that these were my entire compression. Also declare that I been oriented (a) personally about all the pre and post-operative care that should be followed, as well as complications and intercurrences that could happen in this (these) treatment (s). these include the ecchymosis (red spots), edema (swelling), hemorrhage (bleeding), local infections operative or general area, necrosis (tissue death), dehiscence (wound disruption or scar), asymmetry, capsular contracture (hardening of the breast where breast implants), surface irregularities, hypertrophic scar or keloid, pigmented scars, neuromuscular disorders, vascular disorders, thrombosis, embolisms, anesthetic complications, allergic reactions of lesser or greater degree (anaphylactic shock), risks of any invasive treatment or death. I have been informed (a) and am aware of the risks involved in my person and consciously assume.
I am well informed and aware that the final outcome of treatment depends not only on medical work and his team, but also my personal care and especially the unpredictable reactions of my body.
Also, I am aware that smoking (cigarettes or snuff use of any type) and drug use can cause local or general complications, especially in the final healing. In some cases the optimal result warrants further surgical intervention to achieve the best result. Cellulite, stretch marks and sagging can only improve with surgery but not always in full. I am aware that all security measures available in the office or clinic where it will be done my treatment, will be taken into account along with all technical and personal surgeon resources and medical equipment, intended to minimize such potential risks and others not specified above, as well as finding the best possible result for (the) treatment (s) proposed (s).
Being true the foregoing, I sign this document for all legal purposes, in compliance with Article 34 of the Law Practice of Medicine force.