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Hair Transplantation Consent Form

 

Office Use Only	Patient’s Name
	Address
	Date of Birth
	Telephone
	Consultation Date

TO THE PATIENT:

Please ensure you read ALL sections of this form carefully and that you understand all sections before signing. ALL INFORMATION IS TREATED IN THE STRICTEST CONFIDENCE.

I, ______________________   of   ________________________________
(Name of Patient)                              (Address of Patient)

I hereby give permission for the procedure of Hair Transplantation to be carried out on me by Dr. Conor Kiely and his team.

Hair Loss

Men

The most common cause of hair loss in men is a condition known as Androgenetic Alopecia, more commonly known as Male Pattern Baldness (MPB). Women can also develop a similar condition. Androgenetic Alopecia is caused by the interaction of the hormone Dihydrotestosterone (DHT) with specific receptors in the hair follicles. Because not all hair follicles contain receptors to DHT, Androgenetic Alopecia results in hair loss in certain parts of the scalp only, hence the term Pattern Baldness.

Women

In women as in men, the most likely cause of scalp hair loss is androgenetic alopecia—an inherited sensitivity to the effects of androgens (male hormones) on scalp hair follicles. These hormones are produced by the woman’s adrenal glands. Other causes of hair loss in women are: Trichotillomania— compulsive hair pulling, Alopecia Areata, Triangular alopecia, Scarring alopecia and Telogen effluvium— a common type of hair loss caused when a large percentage of scalp hairs are shifted into "shedding" phase. The causes of Telogen effluvium may be hormonal, nutritional, drug-associated, or stress-associated. Loose-anagen syndrome—a condition occurring primarily in fair-haired persons in which scalp hair sits loosely in hair follicles and is easily extracted by combing or pulling. Other causes of hair loss in women are: hormone imbalance, stress, anaemia, iron deficiency or underactive thyroid gland. Women suffering from disorders in. the last group are not suitable for Hair Transplantation and treatment is aimed at correcting the underlying disorder.
Women who are suitable for hair transplant surgery can do extremely well. However we always sound a note of caution in so far as, if the thinning process which has caused the hair loss on the top of the scalp should eventually extend into the donor area, then the transplanted grafts could also be affected.

It is important to note that in women the doctor may need to do a physical examination and /or blood tests to determine the cause of hair loss.

Hair Transplantation

Hair Transplantation is a surgical procedure, by which hair follicles from regions of the scalp that normally never go bald (such as the sides and lower back of the head) is transferred into areas of hair thinning or baldness. This procedure is normally carried out using local anaesthetic and mild sedation. In exceptional cases, where a person has a pre-existing medical condition, general anaesthesia may be required. This is agreed in advance with the patient. The recipient (bald or thinning) area is carefully evaluated and marked. Under local anaesthesia, a strip of healthy, hair-bearing tissue is removed from the donor area of the scalp (usually the back or sides of the head). This strip may measure from 10cm to 25cm in length depending on the number of hair follicles required for transplantation. The donor area is then closed with fine soluble sutures (stitches). This should leave a fine scar which is easily covered by the patient’s hair, providing the patient has not cut his hair too short. The sutures dissolve themselves and do not need removal. The hair grafts are carefully prepared, trimmed and placed into the recipient sites which have been made in the thinning or balding area. In most cases grafts of various sizes are strategically placed into particular zones in order to achieve maximum results. Most grafts are ‘Follicular Units’ which contain 1 to 4 hairs each. More than one Hair Transplantation session may be required to complete a Hair Transplantation programme. Each patient’s results are individual to them. The number of transplantations required depends on certain factors. These factors include the size of the recipient area, the density of new hair growth aimed for, the patient’s donor hair characteristics such as donor density and hair shaft diameter, the rate of original hair loss, future hair loss progression and the patient’s own expectations. Following the procedure the patient should not drive for 24 hours and if travelling home should have a designated person to collect them.

Only the doctor performing the procedure can say what he feels is possible, as hair loss and hair growth is individual to the patient. No specific result can be guaranteed. No conversations with persons from this clinic or any other clinic nor pictures demonstrating previous patient’s results implies a guarantee that a patient’s results will be the same or similar. In most cases the transplanted hair falls out within the first 3 to 4 weeks. The new hair will then grow from the transplanted hair follicles and become apparent between 3 and 5 months after the procedure. It will then continue to grow as normal hair at a rate of about 1 cm per month.

Consultation and Information

I have had a face to face personal consultation with Dr. Conor Kiely and I have had adequate time to consider fully the procedure I am about to undergo.

I have read Dr. Kiely’s website www.kielyhealthcare.com and any literature given to me by Dr. Kiely. I have adequate understanding of the contents and I have asked any questions I have regarding the procedure I am about to undergo and I accept and understand fully all answers given.
The treatment, alternatives, possible side effects and success rate have been explained to me in full and to my entire satisfaction. I fully accept and understand what has been discussed with Dr. Kiely. I have asked any questions that I had and understand and accept fully all answers given.

Forms & Questionnaires

For female patients: If I am pregnant or suspect I am pregnant I will inform Dr. Conor Kiely immediately. I understand that the procedure of Hair Transplantation will not be undertaken if I am pregnant or suspect I am pregnant.
The first day of my last menstrual period is: Day:      Month:      Year:
I understand and accept that it may be necessary for Dr. Kiely to carry out a physical examination and/or do blood tests to determine the cause of my hair loss.

For all patients: I have carefully read, understood and truthfully completed all forms given to me by Dr. Kiely prior to my surgery taking place. The answers I gave in the ‘Medical Questionnaire’ were correct and complete. If, in the period of time between consultation and surgery, I have developed any medical conditions or illnesses and / or I am taking any medication I will immediately inform Dr. Kiely. If I am allergic to any medication I will immediately inform Dr. Kiely. (please complete sections a), b), c) below in CAPITAL PRINT).

a) I suffer from the following illnesses / medical conditions now or in the past:

Type of Illness / Medical Condition	When

b) I am on the following medication/drugs/tablets now or in the past:

Medications / Drugs / Tablets	When

c) I am allergic to the following medications/drugs/tablets now or in the past:

Type of Allergy	When

 

Are there any substances you have used recently not listed above (e.g. recreational drugs)? Please provide details to Dr. Kiely if you have.

The Treatment

The treatment involves the removal of hair follicles from the back of my head, where they are not genetically determined to go bald, under local anaesthetic and transplanting them to the balding or receding area. I fully understand that results cannot be guaranteed and that further Hair Transplantation surgery may be required to achieve a level of coverage and density that cannot be achieved in one session alone. Please see the literature provided by Dr, Kiely and the website www.kielyhealthcare.com.

The Procedure

I consent to and authorise the procedure of Hair Transplantation to be carried out on me by Dr. Conor Kiely and his team.

I consent to and authorise the administration of local anaesthetic agents or any other drug or agent as the doctor sees fit.

I have read and abided by the rules of 'INSTRUCTIONS PRIOR TO VISITING THE CLINIC' and I understand and will abide by the rules of the ‘AFTERCARE INSTRUCTIONS’.

I understand every time an incision is made in the human body a scar will occur, and that every effort will be made to make the scar as inconspicuous as possible. I have informed Dr. Kiely if I have a history of abnormal or excessive scarring.

I consent to and authorise the taking of photographs before, during and after the procedure. These photographs will strictly be used for the purpose of assessing progress and kept in the doctor’s file and cannot be used publicly or for any advertising unless I have given my prior consent to Dr. Kiely.

Side Effects

As with all surgical procedures side effects may occur. Most of these are rare but are mentioned for completeness. I understand and accept that that certain side effects may occur. These may include the following:

• Post operative infection - This is very rare as the blood supply to the scalp is very rich and the patient is commenced on antibiotics.
• Post operative bleeding - Occasionally a graft site or donor area will ooze on the first day after treatment and will respond to pressure when a dry, clean tissue is applied. Haematomas (collection of blood under the skin) are possible in the donor area and are easily treated.
• Pain - There is no pain during the procedure apart from the discomfort of getting local anaesthetic. Mild to moderate pain may occur at the donor area for a few days following treatment and the donor area may be a little sensitive for about a week after treatment. Occasionally a patient may suffer from mild to moderate headache for 24 hours after treatment. Paracetamol or Nurofen Plus (paracetamol and codeine) may sometimes be recommended.
• Itching of the scalp - This is rarely a problem and if it occurs resolves spontaneously.
• Swelling - This usually occurs in about 1 in 10 procedures. If it occurs it begins on the third day post-op and lasts for three to four days. Occasionally it extends down around the bridge of the nose and the eyes and may cause bruising around the eyes. This lasts a few days and can be treated by simple measures such as massaging the area with the fingers.
• Numbness in the donor and recipient areas - This is rare, and may sometimes last a few weeks to a few months. It resolves spontaneously.
• Scabbing of the scalp - After the procedure small scabs occur where the grafts are inserted. These can usually be easily disguised and fall away in 4 to 7 days. Pinkness of the recipient area may last a few days more but is rarely a problem.
• Scarring of the scalp - Scarring at the donor area occurs. This presents as a pale, thin scar the length of the donor strip. This may vary in length or may present as a number of smaller scars. This will not be visible as long as you let your hair grow over it. If you cut your hair very short or shave your head it will be visible. Very occasionally, especially in people with 'stretchy' skin a donor scar will be somewhat wider than normal. Some people may be prone to Keloid scarring. Usually these people will have a history of these scars (e.g. a wide appendicectomy scar) and should inform the doctor of this. It is commoner in people of non Caucasian origin.These people will require an initial patch test. The doctor will identify if this is likely to occur or not.
• Marks at the recipient area - Where the grafts are placed in the recipient area marks are usually very mild and resolve rapidly. Very rarely elevation of the grafts may occur resulting in uneven texture of the scalp. Depression of grafts may occur very rarely also, causing marking or 'pitting' at the base of the grafts. These complications are very rare in our practice.
• Tingling - This may occur but settles down quite rapidly.
• Irregular or uneven delayed hair growth - Most transplanted hairs are shed after each session over a period of 2 to 8 weeks. Generally within 3 to 4 months new hair growth begins. This may occur at irregular rates, with some hairs coarser, finer, darker or lighter in colour, or different in textures to the characteristics of the original hair. In most instances this eventually normalises. However, this may take twelve months or more from the starting point before cosmetically satisfactory results are seen.
• Mild 'Shocking' (Shedding) of existing hair - When there is 'weak' existing hair in the scalp that is transplanted occasionally the transplant procedure can have this mild 'shock like' effect on these hairs causing them to drop out for 3 months, after which they always grow back. This effect is noticed in about 1 in 50 patients and is usually not an issue after the first session has grown in, since then there is strong dominant hair over the area. If a particular hair that is 'shocked' was on one of its last life cycles then it may drop out permanently.
• Epidermoid cysts - These are small sterile cysts which occur when a new graft has been placed 'piggy back' on top of a small amount of skin material which was trapped at he bottom of the new recipient hole. If they occur they are simply treated with hot packs and occasionally with a tiny incision under local anaesthetic.
• Allergy or Reaction to Anaesthetic or Medications Used - If you are known to be allergic to any drug, medication or anaesthetic such as Penicillin you must inform Dr. Kiely. Allergic reactions are extremely rare and medications are kept at hand to immediately deal with this possibility.
• Dizziness or Fainting - Either from anxiety, not having eaten or medications. This is very rare and can be easily treated. We advise all patients to have a full meal before treatment and not to arrive for surgery on an empty stomach.
• Failure to improve my quality of life - Interruption of work, job routine, home or social life, or to live up to my goals or expectations to the procedure.
• Patients with illnesses - If you suffer from an illness (e.g. epilepsy, heart disease, depression, asthma or any other illness) or if you are taking any medication whatsoever you must inform Dr.Kiely . This does not necessarily preclude you from the procedure but Dr.kiely must be informed.
• Others - There is a possibility that other side effects or complaints not mentioned here, or not presently known, recognised or understood may develop in the future.

Please do not hesitate to contact Dr. Kiely if you have any queries or concerns prior to the procedure. See Contact Us

Other Treatments

I understand that other treatment options are available such as:

1. Doing nothing.
2. Wigs/hair pieces/weaves -These do not grow, are made of artificial material or human hair and require lifetime maintenance and replacement.
3. Drugs - Minoxidil and Finasteride - these must be taken for life, have undesirable side effects and baldness returns on stopping these. We (KHC) do not recommend them.
4. Scalp reduction and flaps - these are major surgical procedures and Kiely Healthcare does not offer this type of surgery.
5. Artificial hair implants - These do not grow, cause infection, fall out regularly and require life long maintenance. We (KHC) do not recommend them.

Outcomes and Expectations

I understand and accept that:

The practice of medicine and surgery is not an exact science and as results vary from patient to patient no individual patient guarantees can be given.

Even though Hair Transplantation is, in general, a highly successful procedure I accept that it is not possible to totally guarantee or give assurance of a successful result or to assure an outcome, which will meet my goals or guarantee my happiness.

A number of Hair Transplantation procedures may have to be carried out before the desired cosmetic result is achieved. A single session may not be enough to achieve the desired density and pattern of hair growth. I am not obliged, at any time, to proceed with further sessions, although I will have received this advice as part of a treatment plan from Dr. Kiely.

Even though my initial Hair Transplant procedure(s) may yield excellent results, with time, I may lose more of my non transplanted hair as part of my existing hair loss problem causing further thinning or balding. I may then require further Hair Transplant surgery to address this.

I understand and accept that Hair Transplantation may not live up to my goals and expectations.

I understand and accept that interruption of my work or job routine or interruption in my social or personal life may occur. Dr. Kiely or Kiely Healthcare will not be held liable for such loss.

If my hair Transplantation involves Dr. Kiely carrying out repair or corrective work on a previous Hair Transplantation carried out by another doctor or clinic then Dr. Kiely and his team bear no responsibility for my present condition. He will attempt to correct my condition to the best of his ability, but correcting the work of other doctors is more difficult and the results may not be the same as if the hair transplantation process were started with Dr. Kiely.

I understand that I must not drive nor operate machinery for 24 hours after this treatment. I will arrange for another person to collect me and take me home after
the treatment. I will arrange for another person to be with me for 24 hours after the treatment.

In the rare event of a problem arising following the treatment I will immediately contact Dr. Conor Kiely. His contact number will be supplied to me.

Consent Details

I consent to the administration of local anesthetics, medication, injections, intravenous solutions, and materials to be given by or under the supervision of Dr. Conor Kiely that he may deem necessary in my case.

I am aware of the other alternative methods of addressing hair loss and am instead choosing this plan, as outlined by Dr. Kiely, which includes today’s procedures. These alternatives include doing nothing, wearing a hairpiece, wig or toupee; “hair weaving”, attachment grafts, and topical and pill hair-growth agents such as Minoxidil and Finasteride. A combination of the above is also possible.

I hereby state that all the facts and information, including pertinent facts concerning my past medical and surgical history, that have been furnished to Dr. Kiely and his nurse/assistant during my pre-operative evaluation are complete and correct. I have not withheld any medical information that may be helpful, harmful, or detrimental to my care. I do not believe that I presently have any communicable disease, and do not believe that I have been exposed to, or have, hepatitis, or AIDS (acquired immune deficiency syndrome) or am a carrier of the HIV virus. If at any time during the hair transplant process, there is evidence or suspicion of any of the above or any medical condition, Dr. Kiely reserves the right to suspend any further procedures until necessary tests or treatment are completed by my own personal doctor and written evidence of such is provided to Dr. Kiely. I give Dr. Kiely permission to draw blood for HIV and hepatitis testing, if an accidental needle puncture or break of the skin by a “sharp” should occur to either Dr. Kiely or one of his assistants. This will be done in a confidential manner.

I agree to follow the pre-op and post-op instructions that have been provided to me by Dr. Kiely and/or his nurse-assistant, before, during, and after the surgical procedure, and that I will as soon as possible, notify him of any questionable or untoward conditions that may arise. I agree to take all medications as directed. I will then keep all scheduled and recommended appointments, as advised by Dr. Kiely or his assistants.

I have adequate understanding of the material in the website (www.kielyhealthcare.com) and literature provided by Dr. Kiely and from what he has told me about the procedure. He has fully explained, in terms clear to me, the effect and nature of the procedure being performed today, foreseeable risks involved and alternative methods of treatment.

I know that the practice of medicine and surgery is not an exact science, and that, therefore, reputable surgeons cannot guarantee results. In this regard, I have been advised that the goal of the procedure that I have requested is improvement, rather than “cure” or “removal”, in the appearance or status of my balding or thinning hair condition.

I fully understand the results that I may reasonably expect. I understand hair transplants are not perfect. An explanation of this procedure has been given to me. I do understand that I will not obtain a full head of hair from the procedure. I understand that in hair transplant surgery, no new hair is created and that the success of the procedure lies in the illusion of density created by the redistribution of my donor hair into the recipient site.

I am aware that good results will depend in part upon my completing the necessary number of operations recommended by Dr. Kiely. However, because many variables exist, I have not been promised or guaranteed good results. I also understand that the quality and amount of pre-existing hair are major factors in the eventual result. I understand I will not have hair of the same thickness/density as I had prior to the onset of my hair loss.

I understand every time an incision is made in the human body, a scar will occur, although every effort will be made to make the scar as inconspicuous as possible. I have informed Dr. Kiely if I have a history of abnormal or excessive scarring, or of Keloid scarring. Superficial crusting, pinkness, or redness of the incision areas may occur, but these will likely be temporary. A thickened or raised scar (a hypertrophic scar/keloid) is possible. This is more likely to occur in patients with a history of this type of scarring. Wide scarring is also possible in the donor area.

I understand that all recommendations made during my consultation and treatment are estimates and may change at a later date.

I understand that any ‘before and after’ photographs shown to me are used as a guide only and may not represent my results as patient’s results and expectations may differ.

I have been given an opportunity to ask all questions I desire regarding the matters covered in the preceding paragraphs, and these questions have been answered to my satisfaction. I have read, and thoroughly understand, this consent form. I, therefore, freely and openly consent to this scheduled hair transplant procedure upon myself, which will be carried out by of Dr. Conor Kiely, with the assistance of his team of medical personnel and hair transplant technicians.

Surgeon Declaration

I have explained the contents of this document, as well as related materials and instructions, to the patient, and have answered all of the patient’s questions to the best of my knowledge. I feel that this patient has been adequately informed and has freely, openly, and fully consented to the procedure.
________________________________________

I, the patient named above, have had adequate time to carefully read and understand this Consent Form prior to my procedure. I have had adequate time to assimilate all information available to me concerning this procedure. I also have had adequate time to consult with Dr. Kiely, my own doctor or any other person as I see fit to consult with, prior to making my decision to proceed with Hair Transplantation surgery. I am happy to proceed with this surgery having fully understood and accepted all information available to me.

Having duly considered all available information on Hair Transplantation and having being given adequate time to assimilate and understand this information and to ask any questions I had regarding treatment and having had all my questions answered to my complete satisfaction I hereby consent to the procedure of Hair Transplantation to be carried out on me by Dr. Conor Kiely and his team.

Signed:
Patient: _________________ Date: ____________(dd/mm/yy)

Witness: _________________ Date: ____________(dd/mm/yy)

Doctor: _________________ Date: ____________(dd/mm/yy)

Should you have any questions or need clarification on any aspect of Hair Transplantation surgery please do not hesitate to contact Dr. Conor Kiely on 087 2869030 / 021 436495

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