Treatment agreement

- Patient:

- Date of birth:

- Operation date:

1) I hereby request that B.F.M.L van de Ven or one of his associates, specialists in oral and maxillo-facial surgery, perform an operation, namely:

2) I have been informed of the nature, the goal and the results that may be expected of the operation, as well as of the possible complications as listed at www.drbart.nl.
I have been informed of the possible side effects that may occur after the operation, as listed at www.drbart.nl.
Alternatives to the operation, where present, have been discussed with me, as have the advantages and disadvantages of each of these options. I have had the opportunity to ask questions about the planned operation, and the questions were answered to my satisfaction.
I declare that I have been provided with sufficient information with regards to this operation. In part based on this information, I have, after considering it for a sufficient amount of time, come to a considered decision regarding the operation.

3) I know that during surgery, unforeseen circumstances may result in the necessity to use additional and/or different surgical techniques to those discussed.

4) Provision of general anesthesia is the responsibility of the anesthesiologist. He or she may use any and all registered pharmaceuticals for this purpose.
Provision of local anesthesia is the responsibility of the maxillo-facial surgeon. He or she may use any and all registered pharmaceuticals for this purpose.
I understand and accept that there are normal risks linked to anesthesia, such as for example allergic reactions to certain pharmaceuticals, and possible memories of parts of the operation.

5) I understand that, if necessary, I may receive a blood transfusion.

6) If I feel the need for a talk with the anesthesiologist prior to the procedure, I will make an appointment with him or her via the secretary?s office.

7) I have been informed of the fact that as with any operation, possible complications include: infection, post-operative bleeding, wound healing problems.

8) I am aware of the fact that problems may occur with wound healing if I smoke and/or use nicotine patches. Three weeks prior to and subsequent to the operation, smoking and/or use of nicotine patches is forbidden; nicotine decreases blood flow in the wound area, which can disrupt wound healing.

9) I will follow all of the instructions given to me by Mr van de Ven or his employees regarding the operation to the best of my ability and understanding.
If I am uncertain of anything in the period after the operation I shall ? possibly after consulting my general practitioner first ? contact Mr van de Ven or one of his employees.

10) If unforeseen complications do arise, Mr van de Ven will ensure that I am assisted fully, without Mr van de Ven charging additional fees for this help.
This does not mean that Mr van de Ven accepts financial responsibility or risk for eventual subsequent damage.
If I am faced with additional costs due to complications, I can only bill these to Mr van de Ven if he can be held responsible for the complications.
Mr van de Ven is adequately insured for any necessary civil justice suits.

11) I DO / DO NOT object to photographs and written descriptions of my operation being used on the website www.drbart.nl.

12) I DO / DO NOT object to my e-mail address being placed on the website www.drbart.nl.
If I request it, this information can be removed from the site.

13) I DO / DO NOT object to Mr van de Ven informing my general practitioner about my operation directly.

Location:

Date:

Signature:

Name in block capitals:

If the patient is underage, his or her legal representative must sign this form. From the age of 12 onwards, the minor must co-sign this form.