THIS FORM IS PREPARED TO INFORM THE PATIENT AND THEIR RELATIVES ABOUT THE SURGERY TO BE DONE. IT IS A LEGAL OBLIGATION TO BE READ AND APPROVED. INFORMATION SHEETS TO EXPLAIN PROJECTED RISKS AND UNDESIRED CONDITIONS (COMPLICATIONS) OF SURGICAL TREATMENTS; THEY ARE USED TO PROVIDE INFORMATION ABOUT OTHER TREATMENT OPTIONS. THE IDENTIFIED RISKS HAVE BEEN DEFINED TO MEET THE NEEDS OF MOST PATIENTS IN MANY CONDITIONS. HOWEVER, THIS FORM SHOULD NOT BE CONSIDERED A DOCUMENT CONTAINING THE RISKS OF ALL TREATMENTS. DEPENDING ON YOUR PERSONAL HEALTH CONDITION OR MEDICAL INFORMATION, YOUR SURGEON MAY GIVE YOU DIFFERENT OR ADDITIONAL INFORMATION. DO NOT SIGN THE FORM ON THE LAST PAGE UNTIL YOU HAVE CAREFULLY READ ALL THE INFORMATION WRITTEN BELOW AND FIND THE ANSWERS TO ALL YOUR QUESTIONS
GENERAL INFORMATION:
LARGE AND DROPPİNG BREASTS CAUSE SOME PHYSICAL DISEASES. THESE ARE NECK, SHOULDER AND BACK PAIN, DISTURBING GROWS CREATED BY BRA’S ON THE SHOULDER, PAIN IN THE BREAST, ITCHING AND REDUCING UNDER BREAST. VERY LARGE BREASTS IN YOUNG GIRLS ALSO CAUSES SOME PSYCHOSOCIAL PROBLEMS, THESE ARE USUALLY A REASON FOR EMBARRESSTMENT. IN SOME CASES, GREATNESS IS UNIVERSAL AND MAY IMPROVE THE FEELING OF SHAME. THE FOLLOWING INFORMATION IS USEFUL FOR THOSE WHO SEEK SOLUTIONS TO SUCH COMPLAINTS. IT SHOULD BE INVESTIGATED IF THE GROWTH IN THE BREAST IS DUE TO A HORMONAL PROBLEM. IT SHOULD BE QUESTED IF THE GROWTH IN THE BREASTS CONTINUES. IT SHOULD BE INVESTIGATED IF THERE IS A PAINFUL OR PAINLESS MASS IN THE BREAST. IT SHOULD BE QUESTED IF THERE IS A BREAST INFECTION OR SURGICAL INTERVENTION. SURGICAL INTERVENTION IS CONSIDERED FOR BREASTS THAT ARE NOT GENERALLY DUE TO A HORMONAL PROBLEM, AND HAVE STOPPED GROWTH IN THE LAST 6 MONTHS AND REQUESTED TO SHRINK. BREAST REDUCTION SURGERY IS DONE AFTER BREAST DEVELOPMENT IS COMPLETED. BUT THERE ARE SOME EXCEPTIONS TO THIS. YOUNG GIRLS WITH VIRGINAL BREAST HYPERTROPHY MAY REQUIRE SURGERY BEFORE COMPLETING DEVELOPMENT IN ORDER TO NOT AFFECT NORMAL PSYCHOSOCIAL DEVELOPMENT. TODAY, 12.5% OF ALL BREAST REDUCTION SURGERY ARE PERFORMED IN ADOLESCENT PERIOD. IMAGING TECHNIQUES SUCH AS PRE-INTERVENTION MAMMOGRAPHY ARE USED AT A PARTICULAR AGE AND WITH A REAL MASS. THEN THE TECHNIQUE TO BE USED IS DECIDED ACCORDING TO THE DIMENSIONS OF THE BREASTS, THE FEATURES OF THE SKIN AND THE BREAST GLAND. IF THE CHEST TENSION AND TENDERNESS OCCURS BEFORE PERIOD, THE SURGERY SHOULD NOT BE COMBINED WITH THIS PERIOD.
THE RELATIONSHIP OF BREAST REDUCTION SURGERY AND BREASTFEEDING: FOR NORMAL MILKING, IT IS REQUIRED TO HAVE FUNCTIONAL BREAST TISSUE WITH CONNECTION TO THE MILK CHANNELS AND TO THE BREAST HEAD AND THE SENSITIVITY OF THE BREAST HEAD. AFTER A SURGERY THAT DOESN’T IMPROVE THESE ANATOMICAL AND PHYSIOLOGICAL FEATURES, BREASTFEEDING IS NOT IMPOSSIBLE. Stimulation of the Nipple BY THE BABY CAUSES CONTRACTION IN THE MILK GLANDS AND SECRETION OF MILK WITH A NEURAL AND HORMONAL CYCLE IN WHERE PROLACTIN AND OXYTOSIN HORMONES ALSO PLAY. FOR THIS SUCTION REFLEX TO WORK, IT IS ESSENTIAL TO HAVE THE SENSITIVITY OF THE NIPPLE HEAD. REDUCED SENSITIVITY OF THE Nipple HEAD CAN BADLY AFFECT MILK RELEASE BY INTERRUPTING THIS CYCLE. HOWEVER, IN CONTROLLED STUDIES MADE IN RECENT YEARS, IT HAS BEEN OBSERVED THAT THIS SITUATION HAS REPRODUCED IN THE FOLLOWING MONTHS. IT MUST BE MADE IN THE SAME STUDIES THAT THE SENSITIVITY OF THE BREAST HEAD TO VIBRATION AND PAIN IS DECREASED IN WOMEN WITH LARGE TITLES. BREASTFEEDING IS NOT POSSIBLE IF THE BREAST HEAD IS SEPARATED FROM THE BREAST TISSUE UNDER IT AND APPLIED AS A FREE PATCH. BREAST REDUCTION METHODS APPLIED TODAY, BECAUSE THE BREAST HEAD IS LEAVED DUE TO A QUANTITY OF BREAST TISSUE, THE BREAST BREAST FEELING CAN BE PROTECTED BUT THE AMOUNT CAN REDUCED. THE ELEMENT THAT DETERMINES THE AMOUNT OF MILK PRODUCTION IS THE AMOUNT OF BREAST TISSUE LEFT IN PLACE AFTER THE SURGERY. BECAUSE A MOST OF THE TISSUE REMOVED IN BREAST REDUCTION SURGERY IS FAT TISSUE. Therefore, it has been shown that breast-feeding is POSSIBLE IN BREAST REDUCTION SURGERY PERFORMED
WITH A BREAST HEAD PEDICULATE. IN THE SAME STUDIES, IT HAS BEEN SHOWN THAT THE SENSITIVITY OF THE BREAST HEAD TO VIBRATION AND PAIN IS REDUCED IN WOMEN WITH LARGE TITLES. BREASTFEEDING IS NOT POSSIBLE IF THE BREAST HEAD IS SEPARATED FROM THE BREAST TISSUE UNDER IT AND APPLIED AS A FREE PATCH. BREAST REDUCTION METHODS APPLIED TODAY, BECAUSE THE BREAST HEAD IS LEAVED DUE TO A QUANTITY OF BREAST TISSUE, THE BREAST BREAST FEELING CAN BE PROTECTED BUT THE AMOUNT CAN REDUCED. THE ELEMENT THAT DETERMINES THE AMOUNT OF MILK PRODUCTION IS THE AMOUNT OF BREAST TISSUE LEFT IN PLACE AFTER THE SURGERY. BECAUSE A MOST OF THE TISSUE REMOVED IN BREAST REDUCTION SURGERY IS FAT TISSUE. Therefore, it has been shown that breast-feeding is POSSIBLE IN BREAST REDUCTION SURGERY PERFORMED WITH A BREAST HEAD PEDICULATE. IN THE SAME STUDIES, IT HAS BEEN SHOWN THAT THE SENSITIVITY OF THE BREAST HEAD TO VIBRATION AND PAIN IS REDUCED IN WOMEN WITH LARGE TITLES. BREASTFEEDING IS NOT POSSIBLE IF THE BREAST HEAD IS SEPARATED FROM THE BREAST TISSUE UNDER IT AND APPLIED AS A FREE PATCH. BREAST REDUCTION METHODS APPLIED TODAY, BECAUSE THE BREAST HEAD IS LEAVED DUE TO A QUANTITY OF BREAST TISSUE, THE BREAST BREAST FEELING CAN BE PROTECTED BUT THE AMOUNT CAN REDUCED. THE ELEMENT THAT DETERMINES THE AMOUNT OF MILK PRODUCTION IS THE AMOUNT OF BREAST TISSUE LEFT IN PLACE AFTER THE SURGERY. BECAUSE A MOST OF THE TISSUE REMOVED IN BREAST REDUCTION SURGERY IS FAT TISSUE. Therefore, it has been shown that breast-feeding is POSSIBLE IN BREAST REDUCTION SURGERY PERFORMED WITH A BREAST HEAD PEDICULATE. BREASTFEEDING IS NOT POSSIBLE IF IT IS SEPARATED FROM THE BREAST TISSUE AND APPLIED AS A FREE PATCH. BREAST REDUCTION METHODS APPLIED TODAY, BECAUSE THE BREAST HEAD IS LEAVED DUE TO A QUANTITY OF BREAST TISSUE, THE BREAST BREAST FEELING CAN BE PROTECTED BUT THE AMOUNT CAN REDUCED. THE ELEMENT THAT DETERMINES THE AMOUNT OF MILK PRODUCTION IS THE AMOUNT OF BREAST TISSUE LEFT IN PLACE AFTER THE SURGERY. BECAUSE A MOST OF THE TISSUE REMOVED IN BREAST REDUCTION SURGERY IS FAT TISSUE. Therefore, it has been shown that breast-feeding is POSSIBLE IN BREAST REDUCTION SURGERY PERFORMED WITH A BREAST HEAD PEDICULATE. BREASTFEEDING IS NOT POSSIBLE IF IT IS SEPARATED FROM THE BREAST TISSUE AND APPLIED AS A FREE PATCH. BREAST REDUCTION METHODS APPLIED TODAY, BECAUSE THE BREAST HEAD IS LEAVED DUE TO A QUANTITY OF BREAST TISSUE, THE BREAST BREAST FEELING CAN BE PROTECTED BUT THE AMOUNT CAN REDUCED. THE ELEMENT THAT DETERMINES THE AMOUNT OF MILK PRODUCTION IS THE AMOUNT OF BREAST TISSUE LEFT IN PLACE AFTER THE SURGERY. BECAUSE A MOST OF THE TISSUE REMOVED IN BREAST REDUCTION SURGERY IS FAT TISSUE. Therefore, it has been shown that breast-feeding is POSSIBLE IN BREAST REDUCTION SURGERY PERFORMED WITH A BREAST HEAD PEDICULATE. BREAST FEEDING CAN BE PROTECTED, BUT THE AMOUNT CAN BE DECREASED. THE ELEMENT THAT DETERMINES THE AMOUNT OF MILK PRODUCTION IS THE AMOUNT OF BREAST TISSUE LEFT IN PLACE AFTER THE SURGERY. BECAUSE A MOST OF THE TISSUE REMOVED IN BREAST REDUCTION SURGERY IS FAT TISSUE. Therefore, it has been shown that breast-feeding is POSSIBLE IN BREAST REDUCTION SURGERY PERFORMED WITH A BREAST HEAD PEDICULATE. BREAST FEEDING CAN BE PROTECTED, BUT THE AMOUNT CAN BE DECREASED. THE ELEMENT THAT DETERMINES THE AMOUNT OF MILK PRODUCTION IS THE AMOUNT OF BREAST TISSUE LEFT IN PLACE AFTER THE SURGERY. BECAUSE A MOST OF THE TISSUE REMOVED IN BREAST REDUCTION SURGERY IS FAT TISSUE. Therefore, it has been shown that breast-feeding is POSSIBLE IN BREAST REDUCTION SURGERY PERFORMED WITH A BREAST HEAD PEDICULATE.
THE RELATIONSHIP OF BREAST REDUCTION SURGERY AND BREAST CANCER: HOWEVER, BREAST CANCER IS VERY COMMON IN WOMEN, THE RATE OF BREAST CANCER AFTER BREAST REDUCTION SURGERY IS BETWEEN 0.06% AND 2% COMPARED TO VARIOUS CLINICAL SERIES. ALSO, IN HISTOPATOLOGICAL EXAMINATION OF TISSUE REMOVED AFTER REDUCTION SURGERY IN WOMEN REGISTERING FOR BREAST SIZE, 61% OF NON-CANCER PATHOLOGICAL CHANGES IN THE BREAST TISSUE ARE FOUND. IN THE LIGHT OF THESE FINDINGS, BREAST REDUCTION SURGERY DOES NOT INCREASES THE RISK OF BREAST CANCER, AND IT EVEN CAN BE SUITABLE FOR BREAST CANCER SUGGESTION FOR BREAST CANCER BY PROVIDING REDUCTION OF BREAST TISSUE AND HISTOPATHOLOGICAL EXAMINATION OF REMOVED BREAST TISSUE.
SURGERY: THIS SURGERY IS DONE UNDER GENERAL ANESTHESIA. GENERAL ANESTHESIA MEANS FULLY SLEEPING THE PATIENT AND MONITORING THE RESPIRATORY BY THE ANESTHESIA TEAM WITH A TUBE PLACED IN THE PIPE. SOME LABORATORY TESTS ARE DONE FIRST TO AVOID ANY PROBLEMS. THE ANESTHESIA WILL CONSULT YOU BEFORE THE SURGERY. IN THE OPERATING ROOM, YOUR HEART BEATS AND YOUR BLOOD OXYGEN LEVEL ARE CONTINUOUSLY MONITORED WITH THE HELP OF ELECTRONIC DEVICES DURING THE SURGERY. ALLERGY OR DRUG REACTION CAN OCCUR RARELY AND CAN BE FATAL. FURTHER, SENSITIVE PEOPLE CANNOT BE DETECTED BY ROUTINE TESTS. HOWEVER, WHEN THESE UNDESIRED CONDITIONS OCCUR IN HOSPITAL CONDITIONS, they CAN BE SUCCESSFULLY TREATED AND THE POSSIBILITY OF A PATIENT DAMAGE IS EXTREMELY LOW. BEFORE GENERAL ANESTHESIA, THE PATIENT MUST NOT EAT ANYTHING AND DRINK FOR 6-8 HOURS, WITH AN EMPTY STOMACH. NOTHING IS GIVEN BY ORAL FOR AT LEAST 4-6 HOURS AFTER THE SURGERY. THESE TIMES CAN BE CHANGED BY THE PATIENT’S DOCTOR. THE SURGERY TAKES 1.5–3 HOURS. AFTER THE SURGERY, THE PATIENT IS SENT TO THE ROOM AFTER WATCHING IN THE RECOVERY ROOM, GENERALLY UP TO 1 HOUR. HOWEVER, IF THERE ARE NAUSEA AND SIMILAR PROBLEMS DUE TO ANESTHESIA, THE PERIOD OF STAY MAY BE EXTENDED.
SURGICAL METHOD: MANY METHODS HAVE BEEN DEFINED FOR BREAST REDUCTION SURGERY. WHATEVER THE METHOD IS, A BREAST WITH BREAST-SHAPED IMPROVEMENT AND MORE AESTHETIC PROPORTIONS IS OBTAINED COMPARED TO PRE-SURGERY. HOWEVER, IN REASON TO ACHIEVE A SMALL AND PROPERLY SHAPED BREAST, PATIENTS MUST CONSIDER THE RISK OF SCARING AND REDUCED BREAST SENSITIVITY AND BREAST-BREAKING ABILITY. GENERAL PRINCIPLES IN BREAST REDUCTION SURGERY APPLIED TODAY, ACCORDING TO THE DESIGN MADE WHILE THE PATIENT IS STANDING BEFORE THE SURGERY, BREAST SKIN AND BREAST IMAGIN INVASION AFTER REMOVAL OF EXCESS SKIN, FAT AND BREAST TISSUE; IT IS PLACING THE BREAST HEAD AND AREO IN THE NEW ANATOMICAL PLACE WHILE PRESERVING THE BLOOD AND SENSING OF THE BREAST HEAD. THESE SURGERIES RESULT WITH DIFFERENT PLACED SCARS DEPENDING ON THE METHOD. GENERALLY, RESULT, THE “STICK TRACK” IS ORGANIZED AROUND THE BREAST HEAD IN THE SHAPE OF REVERSE DOWN FROM THE AREOLA AND SITTING INTO THE BREAST CUT OR IN THE SHAPE OF A RACKET PROVING FROM THE BREAST HEAD TO THE UNDERBREAST FOLD LINE. HOWEVER, THIS TRACE IS DISTURBING AT THE INITIAL APPEARANCE, IT GIVES GOOD RESULTS OVER TIME. WHILE THESE SCARS ARE INITIALLY PINK RED; IF THE PATIENT DOES NOT INCLUDE PATHOLOGICAL WOUND HEALING, IT WILL GET FASTER AND WHITE WITHIN MONTHS. SURGERY TIME VARY BETWEEN 2-4 HOURS DEPENDING ON THE TECHNIQUE USED. YOU ARE ALLOWED TO STAND AND FEED AT THE 4TH HOUR AFTER THE SURGERY. DURATION OF HOSPITAL STAY AFTER THE PROCEDURE IS 1-2 DAYS. FOR THE FIRST FEW DAYS, A VACUUM BAG IS USED TO COLLECT BLOOD AND SERUM LEAKS THAT MAY OCCUR IN THE OPERATING AREA. THIS DRAIN IS REMOVED AFTER 1-2 DAYS ACCORDING TO THE AMOUNT INSTALLED. IT IS BENEFITS TO LIMIT ARM MOVEMENTS IN THE FIRST DAYS. THE FIRST WEEK THERE IS A TAPE WRAPPING THE CHEST, THEY ARE REMOVED ON THE 7TH DAY AND ONLY THIN TAPES SHIPPING THE SEWING LINES ARE USED. YOU ARE ALLOWED TO BATHING 48 HOURS AFTER THE DRAINS ARE REMOVED.
OTHER TREATMENT OPTIONS: BREAST REDUCTION IS AN OPTIONAL SURGICAL INTERVENTION. AS OTHER TREATMENT OPTIONS, PHYSICAL THERAPY TO TREAT PAIN COMPLAINTS OR USE LINGERIE TO SUPPORT LARGE BREASTS. LIPOSUCTION CAN BE USED FOR REDUCING LARGE BREASTS IN SELECTED PATIENTS. RISKS AND POTENTIAL SIDE EFFECTS CAN ALSO BE SEEN WITH OTHER SURGICAL TREATMENT OPTIONS. THE RISKS OF BREAST REDUCTION SURGERY EVERY SURGICAL INTERVENTION CONTAINS SOME RISK. BREAST REDUCTION SURGERY HAVE BOTH RISKS AND COMPLICATIONS. THE FUNDAMENTAL FACTOR IN A PERSON’S CHOOSING SURGICAL INTERVENTION IS BASED ON THE COMPARISON OF RISK AND BENEFIT. EVEN IF MOST WOMEN DO NOT EXPERIENCE THE COMPLICATIONS THAT WILL BE LISTED, CONTACT YOUR SURGERY ABOUT EACH TO BE SURE OF THE COMPLICATIONS AND CONSEQUENCES OF BREAST REDUCTION.
1. BLEEDING: BLEEDING DURING AND AFTER THE SURGERY MAY BE OBSESSED, EVEN IF NOT ORDINARY. IF THERE IS POST-SURGERY BLEEDING, EMERGENCY TREATMENT SUCH AS DISCHARGE OF COLLECTED BLOOD OR BLOOD TRANSFUSION MAY BE REQUIRED. DO NOT USE ASPIRIN OR ANTI-INFLAMMATORY DRUGS DURING THE TEN DAYS BEFORE THE SURGERY, BECAUSE IT MAY INCREASE THE RISK OF BLEEDING.
2. INFECTION: IT IS EXTREMELY RARE TO HAVE INFECTION AFTER THIS TYPE OF SURGERY. ANTIBIOTIC OR ADDITIONAL SURGICAL INTERVENTION MAY BE REQUIRED IF INFECTED.
3. CHANGE IN THE FEELING OF THE BREAST HEAD AND SKIN: THERE MAY BE A CHANGE IN THE FEELING OF THE BREAST HEAD AND BREAST SKIN. EVEN BREAST HEAD LOSS OF SENSE CAN BE CONTINUOUS.
4. SCALE ON THE SKIN: ALL SURGICAL INCISIONS CAUSE A STRAIN. THE QUALITY OF THESE STRAINS CANNOT BE ESTIMATED. Abnormal scars can develop in the skin or deeper tissue. IN SOME CASES, scars NEED SURGICAL CORRECTION OR OTHER TREATMENT.
5. UNSATISFACTORY RESULT: THERE IS A POSSIBILITY TO GET INSUFFICIENT RESULTS FROM BREAST REDUCTION SURGERY. THE SHAPE AND SIZE OF YOUR BREAST CAN DISAPPOINT YOU.
6. PAIN: BREAST REDUCTION SURGERY DOES NOT CAUSE PAINS IN THE NECK, SHOULDER AND BACK.
7. HARDNESS: THE BREAST MAY BE EXTREMELY HARDNESS DUE TO AFTER-SURGERY FAT NECROSIS AND INTERNAL SCRATCHING. THIS SITUATION CANNOT BE FORECASTED. A BIOPSY OR ADDITIONAL SURGICAL TREATMENT MAY BE REQUIRED TO THE AREA WHERE FAT NECROSIS OR CAUSE DEVELOPED
8. DELAY OF HEALING: SEPARATION OF WOUND EDGES OR DELAYED IN WOUND HEALING. SOME AREAS OF THE BREAST SKIN OR THE BREAST HEAD MAY NOT HEAL NORMALLY OR IT MAY TAKE A LONG TIME TO HEAL. IT MAY EVEN LOSE THE SKIN AND BREAST HEAD TISSUE. IN THIS CASE, FREQUENT DRESSING OR FURTHER SURGICAL INTERVENTION MAY BE REQUIRED TO REMOVE UNHEALED TISSUE. SMOKERS ARE AT MORE RISK OF COMPLICATIONS IN SKIN LOSS AND WOUND HEALING.
9. ASYMMETRY: ASYMMETRY IS NATURALLY SEEN IN MANY WOMEN’S BREASTS. DIFFERENCES IN THE SHAPE, SIZE OR SYMMETRY OF THE BREAST AND BREAST HEAD CAN ALSO BE SEEN AFTER THE SURGERY. ADDITIONAL SURGERY MAY BE REQUIRED TO CORRECT ASYMEMETRY AFTER BREAST REDUCTION.
10. ALLERGIC REACTIONS: IN RARE CASES, LOCAL ALLERGIC REACTIONS AGAINST TAPE, SEWING MATERIALS OR CREAM APPLIED. A MORE SERIOUS SITUATION, SYSTEMIC COMPLICATIONS CAN CAUSE EVEN DEATH WHEN OBSERVED.
11. ANESTHESIA: THERE ARE RISKS OF BOTH LOCAL AND GENERAL ANESTHESIA. COMPLICATIONS THAT MAY CAUSE EVEN DEATH.
ADDITIONAL SURGICAL REQUIREMENT: THERE ARE VARIOUS CONDITIONS THAT MAY AFFECT THE LONG-TERM RESULT OF BREAST REDUCTION SURGERY. BREAST GROWTH MAY REQUIRE A SECOND SURGERY, EVEN NOT AS IT WAS AGAIN. ADDITIONAL SURGERY OR OTHER TREATMENTS MAY BE REQUIRED IF COMPLICATIONS DEVELOP. RISKS AND COMPLICATIONS ARE NOT COMMON, RISKS RELATED TO BREAST REDUCTION SURGERY HAVE BEEN REPORTED. WHILE GOOD RESULTS ARE EXPECTED, NO WARRANTY OR AUTHORITY CAN BE MADE FOR RESULTS GAINED.
Only for female patients) If I am pregnant, I have been informed that my unborn child carries a risk during examination/medical intervention/treatment/surgery and anesthesia procedures, primarily radiological procedures. I do not have a missed period or pregnancy.
PATIENT’S CONSENT
I was given the above detailed information about my disease and the planned intervention, and the possible complications and risks were fully explained. I was informed that if these develop, treatments, including surgery, may be required, but in some cases, complete cure or recovery cannot be achieved. I accept the implementation of the above-mentioned intervention and other additional interventions that may be required as a medical necessity during the intervention.
to this section;
The statement “I READ, I UNDERSTOOD, I GOT A COPY” written in the patient’s or Legal Representative’s own handwriting will be written..……………………………………………………………………………………..……………………
TO BE FILLED BY THE PATIENT:
Date of Consent:……………………………
Time :………………………………………………
Signature:…………………………………………………………………………………………
Patient’s (guardian or guardian for restricted and minors) Name and surname:……………………………
TO BE FILLED BY THE DOCTOR INFORMING THE PATIENT AND TAKING THE PATIENT’S CONSENT:
Title, Name and Surname of the Physician Receiving Consent:…………………………………………………..
Signature:……………………………………………………………………………………………
TAKING MEDICAL INTERVENTION
Name Surname Title:……………………………………………………………………..
Signature:……………………………………………………………………………………