PATIENT: _____________________________________________________________

DATE: _______________________________

1. I hereby request Dr. Robert H. Stubbs to perform "dermal-fat grafting" surgery on:


(Name of patient) or (Myself)

2. The procedure listed in Paragraph 1 has been explained to me by the doctor and/or his staff and I completely understand the nature and consequences of the surgery. The following points have been specifically made clear:

A. That medicine is not an exact science and complications such as death, although extremely rare, may occur.

B. That swelling, bruising and mild discomfort usually occur in both the donor and recipient areas.

C. That no guarantees with respect to the final outcome or its longevity can be offered.

D. That infection is possible.

E. That sensation may be altered or completely lost.

F. That function may be altered.

G. That delayed healing, nodularity and/or poor scarring may occur. Also, that there will be permanent scars in both the donor and recipient areas.

H. That revisions may be necessary.

I. That the healing process takes time and the final result will not be readily visible for many weeks or even months.

J. That asymmetry may occur.

K. That graft cellular death or fibrosis may occur and that smoking may cause this problem.

L. That chronic or persistent problems may occur which require treatment.

M. That bleeding may occur and should blood collect (a hematoma), this may require further surgical treatment.

3. I recognize that, during the course of the operation, unforeseen conditions may necessitate additional or different procedures than those set forth above. I therefore further authorize and request that the above-named surgeon, his assistants or his designees perform such procedures as are, in his professional judgment, necessary and desirable, including, but not limited to, procedures involving pathology and radiology. The authority granted under this Paragraph 3 shall extend to remedying conditions that are not known to the above doctors at the time the operation is commenced.

4. I consent to the administration of anesthesia, and/or deep sedation, to be applied by or under the direction and supervision of Dr. Robert H. Stubbs or such anesthesiologists as he selects and to use such anesthetics as may be deemed advisable, with the exception of


(None or a particular one)

5. I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees have been made to me as to the results of the operation or procedure.

6. I consent to be photographed before, during and after treatment; that these photographs shall be the property of Dr. Robert H. Stubbs and may be published in scientific journals and/or shown for scientific or educational reasons.

7. I agree to keep Dr. Robert H. Stubbs informed of any change of address so that he can notify me of any late findings, and I agree to co-operate with the doctor and his staff in my care after surgery until completely discharged.

8. I have read the above consent and fully understand the same and do authorize Dr. Robert H. Stubbs to perform this surgical procedure on me.

9. I am not known to be allergic to anything except: (list) _______________________________________


10. I do not desire to have further explanation, discussion or description of the operation, anesthesia or risks involved.

Witness ____________________________ Patient ______________________________________


Patient is a minor _______ years of age, and I (we), the undersigned, am (are) the parent(s) or guardian of the patient and do hereby consent for the patient.

Witness ____________________________ Parent or Legal Guardian _______________________


I agree that the relationship between myself and Dr. Robert H. Stubbs shall be governed by the, and construed in accordance with the laws of the Province of Ontario. Also, I acknowledge that the treatment/service was performed in the Province of Ontario and that the Courts of the Province of Ontario shall have jurisdiction to entertain any complaint, demand, claim or cause of action, whether based on alleged breach of contract or alleged negligence arising out of treatment. The patient hereby agrees that he/she will commence any such legal proceedings in the Province of Ontario and only in the Province of Ontario and hereby submits to the jurisdiction of the Courts of the Province of Ontario.

Witness _____________________________ Patient _____________________________________

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