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Dr. Robert. J. Capriotti M.D.
2530 W. Holcombe Houston TX, 77030

Special Consent to Penis Enlargement with Fat Surgery

Patient: ______________________________

Date:  ______________________________

1. I hereby request Dr. Robert J. Capriotti to perform “penis surgery” on: (Patient name)______________________________

2. The procedure listed above 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 to me.

  1. The medicine is not an exact science and complications such as death, although extremely rare, may occur.
  2. That swelling bruising and mild discomfort usually occur.
  3. That no guarantees with respect to final outcome or its longevity can be offered.
  4. That infection is possible.
  5. That sensation may be altered or completely lost.
  6. That function may be altered.
  7. That delayed wound healing and/or poor scarring may occur.
  8. That revisions or repeat fat injections may be necessary.
  9. That the healing process takes time and the final result will not be readily visible for many months.
  10. That asymmetry may occur.
  11. That fat cell death of fibrosis may occur and that smoking may cause this problem.
  12. That chronic or persistent problems may occur which require 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 in this paragraph 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 J. Capriotti or such anesthesia personnel as he selects and to use such anesthetics as may be deemed advisable, with the exception of  ______________________________.

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.