2 minutes to complete
The donor and the recipient must be above the age of 18 years. If the patient is below the age of 18 years, his or her parent or legal guardian must sign the consent form. The patient should be mentally and physically healthy. The patient must be in a stable financial condition as the surgery is expensive.The donor should be a close family member, preferably his or her child.
Patient Name
Age
Phone number
Address
Why do you want to have a hair transplant?
What are your expectations from the hair transplant surgery?
Are you aware of the risks and complications associated with hair transplant surgery?
Do you understand that the results of hair transplant surgery are not guaranteed?
Are you allergic to any medicines? if any please mention below.
Do you take drugs for any other problems? if any please mention below.
Are you willing to take the necessary steps to ensure the success of your hair transplant surgery?
I am aware of that hair transplantation is only a cosmetic procedure and have been involved in the decision of making about the choice of treatment. I have been explained the pros and cons of undergoing the procedure. I am aware that the procedure will be performed under local anesthesia and give consent for the same.
Signature
Date
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