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Kleinlipo.com

LIPOSUCTION CONSENT
REQUEST FOR SURGICAL SERVICES
Patient's Name _____________________________________Ht/Wt_____________ Max Wt: _________ Date___________ JK NK 100630
I authorize Jeffrey Klein, M.D., associate surgeons, and staff to perform liposuction surgery on the following areas:
Clearance letter required. Must be received at least 4 weeks before liposuction: ___________________ Prior Lipo:
____________________ ____________________ ____________________ (Total $) - (Consult $) = $ Due (Total $) - (Consult $) = $ Due (Total $) - (Consult $) = $ Due ____________________ ____________________ ____________________ Deposit & (Date Paid) Deposit & (Date Paid) Deposit & (Date Paid) ____________________ ____________________ ____________________Balance & (Due Date) ____________________ ____________________ ____________________PreOp Exam Time & Date ____________________ ____________________ ____________________Time / Day / Date of Surgery Time / Day / Date of Surgery Time / Day / Date of Surgery ____________________ ____________________ ____________________6-8 Wk Post-Op Time & Date 6-8 Wk Post-Op Time & Date 6-8 Wk Post-Op Time & Date I understand that if I gain excessive weight between the time of a previous assessments and the day of surgery, the physician reserves the right to change the areas to be treated if the planned areas would result in too much surgery.
The quoted surgical fee remains valid provided that 1) surgery is scheduled and the deposit is paid within 4 months of the date the quote was made, 2) the surgery is done within one year of the quote, and 3) the patient's weight does not increase excessively after the time of the quote. The balance of the fee must be paid at least 21 days before surgery. There is no charge for routine follow-up care after the surgery. However, in the unlikely event of complications, the patient is responsible for fees charged by other physicians or hospitals. In the event of a secondary procedure to correct an unsatisfactory result, the surgical fee will be no more than 50% of the above.
I agree to allow Jeffrey Klein, M.D. and staff to photograph or video me before, during, and after the operation. The photographs, videos, and tapes shall be the property of Jeffrey Klein, M.D., and may be used for teaching, publication or scientific research purposes. The patient's identity will not be revealed. I agree to routine pre-operative laboratory blood tests, including a test for HIV (AIDS). I agree to allow laboratory blood specimens to be obtained to evaluate the amount of anesthetic solution that has reached the circulation, and to measure the amount of blood lost during surgery. I request tumescent local anesthesia and other medications deemed necessary by the surgeon. I authorize the disposal of the liposuctioned fat by a contracted licensed medical waste disposal company.
Liposuction is associated with certain expected temporary side-effects including soreness, inflammation, bruising, swelling, numbness, itching, and minor irregularity of the skin. Some of these effects can take several months to resolve. Scars, changes in skin pigmentation, or an irregularity that persists for more than six months may or may not be correctable by a secondary procedure. Any surgery may involve risks of serious problems and unexpected complications. Although rare, examples of such complications include blood clots, excessive bleeding, scarring, infection, seroma (temporary accumulation of fluid under the skin), hematoma, injury to nerves or other tissues, and allergic or toxic reactions to drugs. In the unlikely event hospitalization is advised after liposuction, I consent to transfer to a hospital and to the release of medical records to and from Jeffrey A. Klein, MD, Inc., and to and from Norma Kassardjian, MD. Jeffrey Klein, M.D. and staff have explained the nature, purpose, possible alternative methods of treatment, the risks involved, and possible complications associated with liposuction and laser liposuction surgery. I acknowledge that no guarantee has been made as to the results. I agree to have any issue of medical malpractice decided by neutral arbitration rather than by jury or court trial. I acknowledge liposuction, including liposuction of female breasts, is performed strictly for cosmetic purposes, is not medically indicated, and is not a covered benefit of health insurance. I know that liposuction should not be done if a woman patient is pregnant; I have no reason to suspect that I might be pregnant. I have carefully read all eight (8) pages of this document, including a copy of the postoperative care instructions, and all of my questions have been well answered. I hereby request and give authorization to the above surgery. ___________________________ __________________________ the 8 pages of this document reviewed __________________________ Patient's Signature at time of Pre-Op Exam Witness's Signature & Date all of patient's questions have been answered. Surgeon's Signature & Date _____________________ ___________________________ Patient Signature
_____________________ ___________________________ Patient Signature
_____________________ ___________________________ Patient Signature
Important Information about Tumescent Liposuction
Risks of Liposuction Surgery: Any surgery involves the risk of infection, bleeding, scarring or serious injury, however tumescent
liposuction has an amazingly good safety record. One of the reasons that tumescent liposuction is so safe is that neither general anesthesia
nor significant IV sedation is required. A recent survey involving over 15,000 patients who had tumescent liposuction without general
anesthesia revealed no serious complications, no serious infection, no hospitalizations, no blood transfusions, and no deaths. The greatest
risks of liposuction are those associated with general anesthesia. By eliminating general anesthesia, the risks of liposuction are dramatically
reduced. Patients can minimize the risk of surgical complications by not taking medications or over-the-counter preparations that might
adversely affect the surgery. Patients should inform the surgeon of any medications being taken either regularly, or occasionally, including
herbal remedies and dietary supplements.
Risk of Irregularities of the Skin: Tumescent liposuction using microcannulas is the least likely to cause any significant or noticeable post-
surgical irregularities of the skin. By magnifying the fatty compartment, the tumescent technique permits more accurate removal of fat, with
greater assurance that the liposuction cannula will not inadvertently approach too near the undersurface of the skin and thereby cause
irregularities. Thus the tumescent technique helps to minimize the risk of post-surgical irregularities or rippling of the skin. Liposuction
might improve pre-existing irregularities of the skin such as dimpling or cellulite, but prospective patients should not assume that there will
be significant improvement. It is unrealistic to expect perfectly smooth skin. Patients should expect that their skin will have approximately
the same degree of dimpling and irregularities as existed before tumescent liposuction surgery. After tumescent liposuction the skin texture
should be within normal limits. A casual observer should not notice any evidence of surgical irregularities of the skin. However, it is
possible that a noticeable irregularity of skin may result. If an irregularity occurs, it may require a corrective procedure for which there will
be a fee to cover the operating room and nursing staff expenses. Because skin tends to lose some of its elasticity with increasing age and with
cumulative sun exposure, older patients may notice an increase of fine wrinkles in areas such as the upper abdomen after liposuction.
Risk of Scarring of the Skin: Incisions for liposuction may result in scarring. Tiny (1 to 2 millimeter) round holes in the skin, called adits,
are used for inserting the cannulas through the skin and into the fat. Typically, when adits heal they become virtually invisible. Although you
may be able to find them upon close examination, most other people would not be able to see them. Some patients may experience temporary
hyper-pigmentation (darkening) that usually fades after several months. Some patients may have a genetic predisposition for persistent
discoloration at incision sites. Any one who has previously experienced hyper-pigmentation or hypo-pigmentation (pale or light colored
scars) of the skin in the past might expect to also experience it with liposuction adits or incisions. Certain areas of the body, such as the back
or upper flanks, may be more likely to have pigmentation changes.
Cellulite: Liposuction of the thighs, while improving the silhouette, does not necessarily eliminate the subtle "puckering" of the skin often
called "cellulite". Cellulite results from the pull of fibrous tissue that connects skin to underlying muscle. While tumescent liposuction may
reduce the degree of cellulite, it is unlikely to eliminate it. Liposuction should not worsen cellulite.
Smoothness of Results: Liposuction can produce some irregularities of the skin which can be visible in certain conditions of lighting. In
general the smoothness of the skin is much improved after microcannular liposuction. These are usually rather subtle, and imperceptible to
the casual observer. It is reasonable to expect significant improvement, but the results are rarely perfect.
Obesity & Liposuction: Liposuction is not an appropriate treatment for obesity. Liposuction is not a substitute for a prudent diet, good
nutrition, and regular exercise. Obese patients may be good candidates for limited liposuction if their goal is simply to improve the shape of
certain limited areas of the body. Obesity is associated with an increased risk of surgical complications.
Postoperative Healing: Normal healing after tumescent liposuction involves a limited but definite degree of soreness, swelling, bruising,
itching and lumpy firmness. A temporary mild numbness, itching or burning of the skin may persist for 2 to 10 months. Most patients can
actually see some improvement of their silhouette within one week after surgery. However, because of the slow resolution of post-surgical
swelling, the ultimate results following liposuction usually require 12 to 20 weeks to be achieved.
Realistic Expectations: Although the results of liposuction are often quite spectacular, it is not realistic to expect perfection. It is impossible
to guarantee the precise amount of improvement that will result from liposuction. Patients should not have unrealistic expectations. Although
patients can usually expect to achieve at least a 50% improvement, it is unreasonable to expect 95% improvement or near perfection. For the
perfectionist, or for liposuction of a very large area, maximum improvement may require a second procedure for which there would be an
additional fee.
Patients who would be satisfied with a 50% improvement would be reasonably good candidates for liposuction. The "50%
improvement" is intentionally a vague measure. It indicates a definite perceptible improvement, but something short of perfection.
If a 50% improvement would make a patient happy, then it is likely that these expectations will be met. Our patients generally
achieve more than a 50% improvement.

Longevity of Results: The fat cells that are removed by liposuction do not grow back. If the patient later gains or loses weight, the change
tends to be distributed proportionately over the entire body. For the best results the patient’s post-op weight should be less than the pre-op
weight. Although one can expect some changes with aging, provided that the patient does not gain large amounts of weight, the patient's new,
more pleasing silhouette is relatively permanent.
www.Liposuction.Com For additional and more detailed information about safety of liposuction.
What to Expect on the Day of Tumescent Liposuction
Arrival: If you arrive during office hours, please check-in at the Dermatology Reception desk (entrance through the door on the
right hand side of the entrance hallway). Otherwise you should enter the Surgery Reception-Waiting Room on the left hand side
of the entrance hallway. Use the telephone located in the waiting room to inform the staff of your arrival. A sign will be posted
with instructions by the phone. A nurse will greet you. After you have signed your surgical-consent forms, you will change into
a surgical gown, and be escorted to the bathroom. Your weight will be recorded, a pregnancy test will be done if indicated, and
the admission interview/questionnaire will be completed by the RN.
Pre-Op Preparations: In the operating room pre-operative photographs will be taken and then the areas on your body to be
treated with liposuction are marked with a blue felt-tip pen. Additional photos of the markings on the body will be taken, and the
patient will be asked to initial these photos to confirm agreement with the areas to be treated by liposuction. This process of
preoperative documentation typically requires 45 to 60 minutes before beginning the infiltration of the tumescent local
anesthesia. For safety purposes we routinely place an intravenous (IV) access in your arm; it consists of a small plastic IV tube
with a rubber stopper on the outside through which medication can be injected if needed. The IV access is much like the car
seat-belt; it is put in place routinely but it is only rarely needed. A blood pressure cuff is placed on your opposite arm, and
cardiac monitor leads are placed on your chest.
Local Anesthesia: Using the smallest needles available, the doctor or the nurse will anesthetize the skin at sites through which
the longer needles or cannulas will be inserted to anesthetize the subcutaneous fat. Patients usually experience a slight pricking
sensation as the skin becomes "numb". A large volume of dilute tumescent anesthetic solution is carefully and gently injected
into the targeted fat. Once an area has been well infiltrated with the anesthetic solution, the fat is usually completely numb. The
infiltration of the local anesthetic is a slow careful process that can take as long to complete as the liposuction itself. After the
infiltration of the anesthetic is complete, but before beginning liposuction, you will be escorted to the bathroom one more time.
Sedatives: Experience has shown that giving a sedative by mouth permits better local anesthesia than when intravenous
sedatives are used. This is because an alert patient is more capable of detecting subtle areas of incomplete anesthesia. A patient
who is too sedated might easily ignore an incompletely anesthetized area, and then feel more discomfort later during liposuction.
Therefore avoiding excessive sedation actually maximizes patient comfort during liposuction. Very few of our patients require
intravenous (IV) sedation. IV or intramuscular (IM) sedation is available for patients who are exceptionally anxious.
Liposuction is accomplished through tiny (1 to 2 millimeter) round holes in the skin, called adits. The adits, which are made in
the skin with 1 to 2 mm biopsy punches, are so small that they need not be closed with stitches. After surgery, adits remain
open for 2 to 5 days and facilitate the post-operative drainage of residual blood-tinged anesthetic solution.
After Liposuction: After completing liposuction, patients are offered a snack and absorbent pads are placed over the adits.
Finally, after the Tumescent Liposuction Compression Garments are pulled on, and the IV access is discontinued, you are ready
to get up and go home. Because of residual local anesthesia, it is several hours after completing the liposuction before any
significant soreness begins. The tumescent technique minimizes post-operative discomfort. Because the residual local
anesthesia lasts for over 18 to 24 hours, plain Tylenol is usually sufficient to treat post-operative discomfort. Post-operative
nausea is unusual after tumescent liposuction. When nausea or vomiting does occur, it typically happens 6 to 12 hours after
surgery after the patient awakens from a nap. This type of nausea and vomiting usually lasts for only one to three hours.
Transportation Home after Liposuction: Patients are not permitted to drive themselves home after liposuction except in the
case of an especially small amount of liposuction where the patient has not received sedation. Although most patients feel well
enough to drive a car immediately after surgery, you must not do so because the large amounts of local anesthesia may cause
some drowsiness. If IV sedation is given during surgery, then the patient must be discharged home under the care of a
responsible adult who is known to the patient. The person who will be driving you home should have a flexible schedule for the
afternoon, although patients are typically discharged in the mid or late afternoon, the exact time cannot be precisely predicted.
BEFORE LIPOSUCTION INSTRUCTIONS
Our office wants to provide you with the very best surgical care. You can help to minimize the risk of complications by carefully
reading and following your preoperative and postoperative instructions. Ask us to clarify any item about which you have questions.
1.
For seven (7) days before surgery do not take ASPIRIN (Anacin, or Bufferin, or Baby Aspirin) or IBUPROFEN (Advil,
Motrin, or Nuprin), or NAPROXEN (Aleve) or any other Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) that impair platelet
function in the normal blood-clotting process. It is permissible to take acetaminophen (Tylenol or Anacin-3).
Please see page 7 for a list of common drugs that contain aspirin.
2.
Do not take decongestants such as Sudafed™ or Actifed™ for 5 days before surgery. Do not take appetite
suppressants such as phentermine (Fastin) for at least 2 weeks before surgery. Do not take Zoloft or other antidepressants and
all herbal remedies, unless specifically approved by your surgeon, for two (2) weeks before surgery. Please see page 6 for list of
drugs that might have adverse drug interactions with the local anesthetic lidocaine.
3.
Avoiding alcohol. We suggest no alcohol during the two days before and two days after surgery (alcohol decreases resistance
to infection). Otherwise drinking a small amount of alcohol (for example no more than a glass of wine or beer per day) is permissible
during the other days of the week before and after surgery. Avoid red wine for 4 days before surgery to minimize bruising.
4.
Do Not Drive Home: Arrange to have someone drive you home after the surgery. It is the patient’s responsibility to make
prior arrangements to have a responsible adult meet and accompany the patient after surgery.
5.
Do not wear unnecessary jewelry, no perfume (deodorant is OK), and minimize use of cosmetics (survival rations only).
Diet before surgery: You should eat a light, low fat meal, such as toast and juice, fruit, dry cereal and/or non-fat milk no
closer than two hours prior to surgery. Avoid whole milk, cream, butter, cheese and other foods that are high in fat content as dietary
fat slows digestion and delays stomach emptying. Please minimize caffeine the day of surgery. You will be given a snack as soon as
surgery is completed.
7.
Changing your dressing the morning after surgery is easier if you have someone to help you. You do not need to purchase
dressings or garments as they will be provided by our nursing staff and sent home with you after the surgery.
8.
Loose Clothing on the day of surgery: There is usually quite a lot of drainage of slightly blood-tinged anesthetic solution
after surgery. Since this drainage might stain clothing, we suggest that you choose your clothing with this in mind. Because we will
apply elastic support garments on top of some bulky absorbent gauze, padding your clothing should be very loose and comfortable.
Women: Wear a comfortable bra that you would not mind getting stained from the blue ink that is used to mark the surgical areas.
Do not wear an exercise sports bra if you are having liposuction on your abdomen or torso.
Men: Speedo-type swim trunks are the easiest type of garment to wear into the operating room for surgery. Jockey-type underpants
are acceptable. Boxer-type underpants are less convenient during the surgery, and may interfere with the surgeon’s liposuction
technique. Bring extra underpants to wear after surgery.
9.
Bring warm socks to prevent cold toes during surgery. If you tend to get cold hands, you are welcome to bring clean mittens
(no leather gloves) to wear during the surgery. The operating room is kept relatively warm, about 72 to 75oF.
10.
Do not use moisturizers or soap that contains moisturizers for at least a week before surgery. Tape and EKG electrodes will
not adhere or stick well to moisturized skin. The ink markers used to outline the areas on your body to be treated by liposuction will
rub-off too easily if you have recently used a moisturizer.
11.
Towels & Plastic Sheets. Plan ahead and avoid staining the car seat with blood-tinged anesthetic solution: Bring a towel, and
a plastic sheet (such as a trash can liner) to cover the car seat during your ride home. Prior to surgery pad your bed at home, and
your living room chair with towels and plastic. Some patients have found it comfortable and convenient to place a felt-backed vinyl
tablecloth on the bed, with the felt-side up. Be careful to avoid allowing drainage to stain carpets.
12.
Do not fast or undergo dramatic weight loss just prior to surgery. All patients should be on a stable, healthy, well balanced
diet for at least 2 weeks before surgery. Liquid diets, extreme low calorie diets, and rapid weight loss diets may predispose to cardiac
irregularities, surgical complications, and poor wound healing.
13.
Music to Relax By: Patients usually enjoy listening to soothing quiet music during surgery. We have a large selection of
music CDs. If you have any favorite CDs which you would like to share with us on the day of surgery, you are welcome to bring them with you. Please label the plastic case that holds your CD so that we will know to whom it belongs.
AFTER LIPOSUCTION INSTRUCTIONS
1) Going Home: You should not drive yourself home. It is recommended that a responsible adult be with you on the day of surgery.
Diet: Resume your usual diet immediately. Drink adequate amounts of water, fruit juices or soft drinks to prevent dehydration.
DO NOT drink alcohol 48 hours before or after surgery.
2) Activities: Quiet rest is recommended immediately after surgery. After surgery do not drive or operate hazardous machinery the rest of
the day. Do not make any important personal decisions for 24 hours after surgery. Later in the day or evening you are welcome to take a
short walk if desired. The day after liposuction surgery you should feel well enough to drive your car and engage in light to moderate
physical activities. You may carefully resume exercise and vigorous physical activity 2 to 4 days after surgery. It is suggested that you begin
with 25% of your normal work-out and then increase your activity daily as tolerated. Most people can return to a desk job within one to two
days after surgery, although one must expect to be sore and easily fatigued for several days.
3) HK Absorbent Pads™ are placed over the treated areas to absorb the large volume of drainage of blood-tinged anesthetic solution during
the first 24 to 48 hours after surgery. The HK Pads are held in place by elastic garments. Beginning the next morning after surgery, change
the HK Pads twice daily. During the first few hours after surgery, if you discover some drainage leaking around the larger HK Pads, simply
apply a small absorbent ABD pad over the area by sliding it under the garment.
4) Post-Op Elastic Compression Garments™. After tumescent liposuction post-op garments are worn in order to: hold the absorbent pads
in place, provide compression to minimize bruising, and maximize the drainage of blood-tinged anesthetic solution. The morning after
surgery, when the garments are first removed in order to take a shower, the patient may experience brief dizziness and lightheadedness
similar to what one experiences when standing-up too quickly. It is the result of rapid decompression of the legs after the elastic garments are
removed. If dizziness occurs, sit or lie down until it passes. Dizziness is reduced by first removing the outer garment and waiting 5 to 10
minutes before removing the second garment. Beginning the day after surgery, you must remove the post-op Garments™ twice daily and
take a shower. You may wash the garments at these times. Some body areas require two garments, others areas only one garment plus elastic
binders (belts). These should be worn day and night until all the drainage has completely stopped plus an additional 24 hours. Do not
be concerned if you drain for several days. Notify us if the drainage persists for more than 8 days. Discontinuing the use of the garments and
binders too soon may result in more prolonged drainage. Typically, patients will need to wear the garments for a minimum of 3 to 6 days,
although many choose to wear the garments longer because of the comfort they provide. Wearing the post-op garment for more than the
minimal number of days is of no significant advantage in terms of the ultimate cosmetic results. After liposuction of Chin, Cheek, & Jowls,
absorptive pads are positioned and held in place by a Spandex head-garment; next a 2 inch-wide black elastic band is placed under the chin
and over the top of the head and worn for one hour giving extra compression to minimize bruising. Drainage lasts 1 to 2 days.
5) Managing Post-Op Drainage: One should expect a large volume of blood-tinged anesthetic solution to drain from the small incisions
during the first 24 to 48 hours after liposuction. In general, the more drainage there is, the less bruising and swelling there will be. During
the first 36 hours, you should sit or lie on towels. When there is a large amount of drainage, it is advisable to place a plastic sheet beneath the
towel. Super-absorbent dressings are worn under the compression garment for at least the first 36 hours. When drainage has nearly stopped,
patients need only place thin absorbent gauze dressings or small pads on incision sites that continue to drain.
6) Wound Care & Bathing: Keep adits (tiny round incision holes) clean. Shower once or twice daily. First wash your hands, then wash
adits gently with soap and water; afterwards gently pat adits dry with a clean towel. Apply new absorbent dressings. Adits that have stopped
draining no longer need padding. Take antibiotics as directed until the prescription is finished. Take antibiotics with food. Call our
office or your surgeon if you notice signs of infection such as fever, foul smelling drainage, or focal redness, swelling, and pain in a treated
area; if you cannot contact your surgeon go to an emergency room. If you believe you have a severe emergency call 911.
DO NOT apply ice-packs or a heating pad to the skin of liposuction areas for at least 4 weeks following liposuction.
DO NOT apply hydrogen peroxide or plastic Band-Aids to incision sites.
DO NOT soak in a bath, Jacuzzi, swimming pool, or the ocean for 7 days after surgery.
7) Common side-effects of tumescent liposuction: Menstrual irregularities with premature or delayed onset of monthly menstruation is a
possible side effect of any significant surgery. Flushing of the face, neck and upper chest may occur after liposuction surgery and usually
lasts for a day or two. Slight temperature elevation during the first 48 hours after surgery is a natural consequence of the body's reaction to
surgical trauma. Discomfort and soreness is worse the second day after surgery, then improves daily. Two extra-strength Tylenol taken
every 4 hours, while awake, for the first 48 hours, will reduce the inflammation, swelling, and soreness associated with surgery. Do not take
aspirin or ibuprofen or medications that contain these drugs, such as Bufferin and Anacin, or Advil or Nuprin for 3 days after surgery; these
can promote bleeding. Bruising is minimal with tumescent liposuction. Nevertheless, the more extensive the liposuction surgery, the more
bruising one can expect. Pain and swelling due to an inflammatory reaction to surgical trauma may occur and increase 5 to 10 days after
surgery; this is treated with antibiotics and anti-inflammatory drugs. Itching of the treated areas several days after surgery may occur as part
of the normal healing process. To help relieve the itching, you may try taking Benadryl as directed on the packaging. Be aware that
Benadryl causes drowsiness. Provided all incisions are closed, soaking in an Oatmeal bath preparation may relieve some of the itching.
Benadryl and Oatmeal products may be purchased without prescription at most drugstores.
7) Schedule Follow-up Appointment at our office for approximately 6 to 12 weeks after surgery. You are welcome to return to our office
for follow-up visits at no charge as often as you like. Please contact us by telephone if you have any urgent questions.
Surgery Center
Jeffrey Klein, MD
Norma Kassardjian, MD Jo-Ann Coker, NP
Atoussa Cameron NP
Patient Signature __________________________________ RN Signature ____________________________Date:________________ Medications and Foods that POTENTIALLY Interact with Tumescent Anesthetic
Consult your surgeon if you are taking any of the following:
Anesthetics
Anti-Arrhithymics
Anti-Secretory
Benzodiazepines
Anti-Asthmatics
Antibiotics/Anti-Microbials/Anti-Infectives
Beta Blockers
Calcium Channel Blockers
Corticosteroids
Anti-Convulsants
Hormones
H2 Blockers
Anti-Depressants
Immunosuppresants
Miscellaneous
Anti-Diabetics
Anti-Fungal Medications
tacrine (Cognex) (reversible cholinesterase) Protease inhibitors/Antivirals
Anti-Histamines
Anti-Neoplastics
Anti-Psychotics
MAO Inhibitors may interact with certain sedatives and
Information About Prescriptions & Medications
1. Antibiotics, such as cephalexin (Keflex™) relatives of penicillin, or doxycycline a relative of tetracycline, are to be taken in order to
minimize the risk of a surgical infection. Antibiotics should be taken with food to reduce the risk of gastric upset. Please start taking your
antibiotic the day before surgery, and continue until the entire supply is completed. If your surgery is scheduled to begin in the early morning
(before 9:00 a.m.), taking your antibiotic and eating should be postponed until after surgery.
2. Lorazepam (Ativan™) is a mild sedative, and a mild sleeping pill, that does not make one feel "drugged". Surgery is more easily
tolerated if the patient is well rested and relaxed. We suggest that you take one lorazepam (1 mg) the night before surgery.
3. Mephytone (vitamin K) will theoretically minimize bleeding and postoperative bruising. Although it is not essential to take vitamin K,
we do recommend it. Take one 5 mg tablet daily, beginning two weeks before the surgery.
4. Acetaminophen (Tylenol™ Extra Strength), 500 mg capsules or tablets, does not require a prescription. Taking two tablets, three to
four times daily, beginning after surgery, should help minimize postoperative swelling. To treat any minor pain before surgery take 2
Extra Strength Tylenol (500 mg), as needed. If Tylenol is not acceptable, notify us so that we can arrange a suitable substitute.
5. Diphenhydramine (Benadryl™) 25mg capsules or tablets, does not require a prescription. Taking as directed can help to reduce post-
operative itching. Be aware that Benadryl™ may cause drowsiness. Medication Precautions for Surgery Patients
1. Do Not Take ASPIRIN (Anacin, or Bufferin) or IBUPROFEN (Advil, Motrin, or Nuprin), or NAPROXEN (Aleve), or any medications
that contain these drugs or any similar anti-inflammatory medications, for seven (7) days before and 3 days after surgery. These drugs will
promote bleeding and bruising. Check the labels of all your medications, even those which you purchase without a doctor's prescription, to
be sure you are not taking any aspirin or aspirin-like substances. Remove any products containing aspirin from your medicine chest so that
you do not inadvertently take it during the week before your surgery. Consult your physician before you stop taking any prescribed
medicines. Please inform us if you are taking any medications to treat arthritis, or any blood-thinning anti-coagulant medications. Below is a
list of medications that must be stopped seven (7) days before surgery.
Advil
2. Do not take decongestant medication containing pseudoephedrine (Sudafed™, Actifed™) for 5 days prior to surgery. These can
cause the heart rate to beat too rapidly.
3. Appetite suppressant drugs phentermine (Fastin), should not be taken for at least 14 days before surgery. Do not stop appetite
suppressants abruptly as you may have side effects. To avoid side effects such as depression, it is better to begin decreasing the dose
gradually two weeks before surgery. Maintain a healthy diet and stop aggressive weight loss diets for a safe surgery and good healing.
4. Do not take antidepressants, such as Zoloft or tricyclics for 14 days before surgery. Please consult you prescribing physician before
discontinuing any of your prescribed medications.
Liposuction Preoperative Check-List. Please initial each item to confirm your agreement. Print "NO" if you disagree.
______ Circle the following locations where we can telephone you (Cross-out if NO):
______ Circle the following locations where we can leave a message (Cross-out if NO): Please provide the telephone number(s) where we can call you.
______ I permit visiting physicians or nurses to observe my surgery.
______ I permit Dr.Klein to show my pre-op & post-op photos to prospective patients, (no name will identify the photos).
______ I agree to avoid aspirin and ibuprofen for 7 days prior to surgery, and to avoid decongestants for 5 days prior to surgery. I understand it
is recommended that all aspirin and ibuprofen products be removed from my medicine cabinet. It is OK to take Tylenol .
______ I will not take Fastin (phentermine), Zoloft, Erythromycin, Biaxin, Diflucan, Nizoral (ketoconazole) and all herbal remedies (unless
specifically approved by my surgeon) two (2) weeks before surgery. ______ If, before surgery, another physician prescribes new medications for me, then I will notify the nursing staff as soon as possible.
______ I won’t take narcotics (Vicodin, Codein, Percocet, Darvon, Darvocet, Fiorinol, Fiorocet, etc) without approval of my liposuction surgeon.
______ I agree to leave valuables at home or in the care of a responsible “family member”. Dr. Klein is not responsible for lost valuables.
______ I agree to arrange to have a responsible adult to accompany me after surgery, to not drive myself home after surgery, and to not drive an automobile until the day after surgery. I will return for a follow-up visit 6 to 8 weeks after my liposuction surgery.
______ If I develop a rash, skin infection, open wound or illness anytime prior to surgery, then I will notify my surgeon as soon as possible.
______ If your pre-op exam and labs are done out of town by your own primary care doctor, then you guarantee that the results will arrive at our office at least one month prior to surgery.
______ If my surgeon requires a clearance-letter from my primary care physician or a specialist to verify liposuction will be a safe procedure for me, I understand this letter must arrive at least 4 weeks before surgery. My surgery date cannot be finalized until this letter is received. If
this letter is not received 4 weeks before surgery, then my liposuction surgery may have to be rescheduled to a later date. I authorize the
disclosure/exchange of protected health information for the purpose of treatment and obtaining medical clearance.
Cosmetic Surgery Policies
______ Payment Schedule: It is our office policy to ask patients to pay half of the total surgery fee as a down payment at the time the surgery is
scheduled. The balance of the fee is to be paid 21 days before the surgery. Final payment may be made with personal check, cashier's
check, cash, or credit card (Visa, MasterCard, American Express). Please make checks payable to JAK Klein, MD, Inc. If final payment
is not received by 21 days before surgery, your surgery date will be automatically cancelled and your deposit, minus $750 for
expenses, will be returned.

______ If I choose to pay my remaining balance by credit card, then I authorize Jeffrey A. Klein, MD, Inc, to charge my credit card on file.
______ Rescheduling Charges: If it is necessary to change or cancel the date of the surgical procedure, then at least three week notice is required.
A $400 rescheduling fee will be charged for any schedule change requested by the patient with less than three weeks notice. A $300
additional rescheduling fee
will be charged if your surgery date is rescheduled more than a total of two times for your convenience or by
us because you have not completed the pre-operative laboratory tests or have not obtained a required letter of medical clearance in a timely
manner. If all preoperative laboratory results and any necessary medical clearance letters are not received by 21 days prior to surgery,
your date will be forfeited and rescheduled. Last minute cancellations due to illness must be well documented in writing by a physician,
including a copy of the physician's physical examination and diagnosis. It is the patient’s responsibility to document the date and time, as
well as the name of our office staff member who received the notice of cancellation or change in scheduled surgery date. If you would like
to revise the plan of body areas designated for liposuction, you should notify us at least one week before surgery.
______ Cancellation Charges:
With at least 21 days notice, a $750 cancellation fee will be charged if surgery is cancelled for any reason after the pre-operative physical
examination and laboratory studies have been completed. This includes a cancellation by you for any reason or a cancellation by us for
medical reasons discovered from results of your preoperative medical examination or laboratory tests ($250 for laboratory fees and an
additional $500 dollars for the consultation, medical examination, and administrative overhead expenses).
With less than 3 weeks notice, if you cancel for any reason, or if the surgeon must cancel the surgery because you have not complied with
explicit instructions, then half of the total surgical fee will be forfeited. If, with less than 3 weeks notice, you first reschedule the surgery
and later cancel the surgery altogether, then half of the total surgical fee will be forfeited. If a surgery is cancelled with less than 3 weeks
notice, it is usually impossible to arrange for another patient to fill that surgical time-slot. Thank you for your understanding in this matter.
Cancellation or a reschedule less than 48 hours of the time of surgery for any reason will result in forfeiture of the entire surgical fee.
______ Pre-Op Telephone Calls: Our staff routinely telephones patients for confirmation two to four days before surgery. If we are unable to
reach you, please telephone us 48 hours before the surgery to confirm the exact date and time of arrival.
I have read the above policy and consent to the routine pre-operative laboratory studies including Hepatitis C and HIV tests. The results of these tests will be placed in the patient's chart and will remain strictly confidential as required by law.

Source: http://www.kleinlipo.com/wp-content/uploads/2010/12/LiposuctionConsent.pdf

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