Patient Nr:
Name&Surname:
Age:
Section Of Plastic Reconstructive And Aesthetic Surgery
HAIR TRANSPLANT SURGERY INFORMATION AND
CONSENT FORM
Section:
Date:
Dear Patient/ legal representative;
Your health situation / about the patient’s health situation and to you/ your patient recommended medical,
surgical or diagnostic procedures and all of these alternatives, benefits, risks and even losses on which you
are informed, you have the right to accept or to refuse or to stop all or a part of them at any stage of the
procedures.
This document we want you to read and understand, is not to scare or keep you away from the medical
practices. It is there to inform you about the consenting of the practices and to get your approval.
INFORMATION
Preliminary diagnosis:……………………………………………………………………….
Planned Treatment:………………………………………………………………………….
Hair Transplant Operation
The hair transplant operation process, where the grafts are taken from the donor area and placed to the
required place.The aim of this operation is to transplant the grafts on the balding or thinning area, to achieve
a better appearence than now. To achieve a no unshed hair or bushy hair structure is impossible. The result is
depended on the success of surgical method but also on the hair cords, thickness, shape, color of the hair and
hair loss. It may take 2 or 3 sessions to achieve the best result of the operation.
This operation will be performed under local anesthesia. Due to the anesthesia allergy or drug reaction may
be seen rarely. However, unwanted situations can be treated, because of the taken measures and the
possibility of a damage are very few.
The operation will take 3-10 hours.The winding after the operation has to stay 1 day.
Because of the scar wound infection at the donor site, the wound healing can be problematic. However, due
to a good blood supply of the scalp, the possiblity of this kind of problem is low and even though it is easy to
heal.
To reduce the possibilty of problems after the operation you have to take the antibiotics, pain killers and
other drugs which are proposed from the doctor without delay and laundering process should be continued
on a regular basis.If there are any questions about the operation firstly you have to see the doctor.
The transplanted hair wil begin to grow after 3-4 months.A part of the transplanted hair may fall.
Accordingly, at a part of the transplant place can be seen traces. However, this problem is not to disrupt a
person's appearance.
CONSENT
I have read the information above and I have been informed by the surgeon of the signature below
mentioned. I have been informed about the purpose of intervention is to do, risks, complications and
treatment interventions. Whithout any other additional explanation, without being under any pressure I agree
this process.
By any loss of awareness of my mentality would occur while the treatment where I can not give a decision,
I want the responsible surgeon to make the necessary decision for my own goods.
………………………………………….(write in handwriting that I understood and I agree everything I read
at the below.)
Patient
Name Surname:
Signature:
Date/ Time:
The patient's attorney / legal representative*
Name Surname:
Signature:
Date/Time:
The patient / patient companion whose name is stated above agrees with the reasons and benefits of this
initiative, the postoperative care, expected risks, type of anesthesia that will be applied for the initiative and
the risks and complications of the anesthesia were adequate and satisfactory explained.
Patient / patient companion confirmed this form that they are pretty well informed about the procedure with
their own will.
Doctor
Name/Surname:
Signature:
Date/time:
If the patient has any Language / Communication problems;
I translated the remarks made by the doctor to the patient. In my opinion the translated information is
understood by the patient.
Translator
Name/ Surname:
Signature:
Date/Time:
Name Surname ( with handwritting) :…………………………………..
* Legal Representative: For those under guardianship of guardians, minors, to parents, their legal
heirs in the absence of 1st degree.
This does not eliminate the statutory rights of the patient by Signing this consent form.