Dr……………………………….,
As requested and to abide by all legal requirements, I would like to:

1. Confirm that I am fully aware of all major and minor risks involved in all surgical procedures and particularly in…………….……..surgery, which I would be undertaking.

2. Declare that I have had the opportunity to forward my queries regarding this procedure and I am now fully aware that this surgery, like any other surgery, not only does it involve risks and complications but also it is unpredictable in all aspects such as the length of the operation, lesion marks and unexpected risks.

3. Confirm that I am fully informed of all risks related to the anaesthesia process. Any further information will be clarified when I consult the anaesthetist.

4. Declare that I have stated, to the best of my knowledge, all up to date information related to all surgery undertaken, treatment or medication.

5. Confirm that I had all the information I needed in order to apply for this surgery.

6. Declare that both parties (myself and my surgeon) agreed to have 7 days time span between aknowledgment of the quotation and the procedure.

7. Declare that the decision to take up surgery is made on common accord between:

• The patient who is fully informed of all risks and complication and is genuinely motivated to undertake cosmetic surgery.

• The surgeon who has used his expertise to explain all the techniques appropriate to his/her case and the terms and conditions of the surgical procedure.

Once decision is made, the common concert agreement aforementioned requires regular medical process, which allows the surgeon to provide to his patient the best techniques available.
Post surgery side effects, if any, will then be discussed by both the patient and the surgeon and treated to such standard as that of the actual operation and post surgery.

I trust that you will use all means available to you to get to the end results expected.


Yours faithfully

signature………………..on …./…./……