INFORMED CONSENT FOR HAIR TRANSPLANTATION SURGERY

Follicular Unit Excision (FUE) Donor Harvesting Method

I, , hereby grant permission to and the team, to perform a Follicular Unit Hair Transplantation procedure (hair transplantation) that includes harvesting the hair via Follicular Unit excision (FUE), the administration of anesthetics and sedatives, by oral or intramuscular routes, as may be necessary or desirable to do this procedure for the treatment of hair loss. FUE may be performed manually and/or by motorized instruments. I understand that my condition has been explained to me as male / female pattern baldness.

I understand that the ability to harvest grafts through FUE is patient dependent and may vary in different parts of a patient�s scalp, face, or body. If, in the doctor�s judgment, the yield from extraction is, or becomes, too low during the procedure, the doctor may decide not to proceed with FUE. In this case the harvesting may be terminated or, with the patient�s permission switched to FUT (strip harvesting) which will leave a linear scar.

Please initial A or B: Option to Convert to FUT (strip harvesting procedure)

A: If, in the doctor�s opinion, the yield from donor extraction becomes unacceptably low, I consent to FUT (strip harvesting).

B: If, in the doctor�s opinion, the yield from donor extraction becomes unacceptably low, I prefer to stop the procedure.

The FUE procedure has been thoroughly explained to me by the physician, and I fully understand the nature and consequences of the procedure. Team has explained to me that the donor area may need to be shaved in order to extract the follicular units.

I understand that the procedure of hair transplantation is cosmetic in nature and that I have the option of doing nothing at all, wearing a hairpiece, using medications to treat the hair loss and surgical options such as hair transplants. I understand that there are different ways to perform hair transplants and various harvesting methods including strip harvesting and follicular unit excision, both manually and motorized. These options have been discussed with me and have also been explained in the numerous informational materials made available to me by the clinic�s team.

I fully understand that this procedure has limited application. I am aware that the practice of medicine is not an exact science, and I acknowledge there are no guarantees as to the outcome of the surgery/procedure and/or need for additional medical and/or surgical treatment. I understand that there are risks involved in any surgical procedure or treatment and that it is not possible to guarantee or to give assurance of a successful result or to assure an outcome that will meet my goals. This document describes the most common risks associated with hair transplantation surgery.

Other risks, though rare, may exist. I recognize that I have been given every opportunity to ask questions and I have made the decision to go forward with the surgery. I clearly understand and agree to the planned surgical procedure.

I have been told that hair transplantation is a generally safe procedure; however, I realize that the following are possible events or complications that may occur.

Team has discussed in detail with me the information that is summarized below:

A. Nature and purpose of Hair Transplantation
Hair transplantation is a procedure which utilizes donor hair in bald areas of the scalp to minimize male patternbaldness.

In hair transplantation surgery, grafts of skin which have hair roots (follicles) are taken from the donor areas (commonly scalp, beard, and body hair). These grafts are then placed in the bald area. Patients can usually return towork in 1 to 4 days, but this can vary depending upon the area of the transplant, and the amount that was transplanted.

The grafts will scab over and these scabs will fall off in about 7 to 14 days. The hair shaft in the grafts willtemporarily fall out about 2 to 3 weeks after surgery (the follicle stays alive in the scalp). The hair will begin to Re-grow beginning about 3 � 4 months after surgery.

Unless informed otherwise, you will be undergoing �follicular-unit� hair restoration. You agree that you understandand accept the following by writing your initials at each of the following statements:

______ Follicular-units are microscopically dissected grafts that contain 1 - 4 hairs each.
______ The percentage of 1, 2, 3 and 4 hair grafts vary from person to person.
______ The primary purpose of using follicular-unit grafts is to obtain a natural look (a non-pluggy look).
______ Density is related to the number of grafts placed in a given area. Density will decrease as a fixed number ofgrafts are spread over a larger area.
______ It is commonly recognized that one needs approximately 50% of their original density to have the appearanceof high density hair. A 50% density requires approximately 50 grafts per square centimeter. Grafting beyond 50% isunrealistic for most patients with advanced balding patterns since it could compromise density in the donor region.
______ Other factors contribute to the appearance of density: fine hair, low follicular-unit hair counts and a dark haircolor/light skin color combination can increase the 50% density requirement needed for producing cosmeticallyacceptable density.
______ There are limits to the density that hair can be planted in a single surgery, as increasing the graft densitywithin a zone of thinning hair increases the risk of �shock-loss� to the thinning hair.
______ Unless dense-packing is performed (approximately 50 grafts per square centimeter or more), multiple sessionswill be required to achieve the appearance of high density. Session number requirements for high density hair varydepending on the grafting density performed during any given procedure.
______ Cosmetically acceptable density varies from person to person. Your long-term density potential is based ongraft availability from your donor region. Donor hair supply typically diminishes with time, especially if the baldingprocess has not stabilized.
______ When more than one surgery has been recommended at consultation, it is common and expected that a patientmay perceive the density of the first surgery as being thin hair rather than thick hair. As stated above, more than one surgery is often needed in order to meet density (thickness) expectation.

B. Risks
______ I understand that among the known risks are bruising, infection, discomfort at the donor and or recipientsite(s), numbness, redness (the degree of redness varies between individuals) infection, swelling, allergy to suturematerial, foreign body reaction, bleeding, swelling, temporary or permanent hair loss, shock loss and or no growth oftransplanted hairs.
______ I understand that FUE carries additional risks over strip harvesting such as increased risks of transaction offollicular units during the extraction process, increased overall scarring in the donor area, poorer growth, and theability to extract less grafts per surgical session.
______ SCARRING: Every time an incision is made in the human body, a scar will occur, and the final appearance ofthe scar can vary between individuals. Every effort will be made to make any scarring as inconspicuous as possible.

Thickened or raised scars (hypertrophic/keloids). Significant scarring is more likely to occur in people who have had ahistory of excessive scarring or who have had previous transplants taken from the donor area. I have informed the practitioners at the clinic that if I have a history of keloid formation.

______ Additional information for patients who select option A FUT/Strip Harvesting: The donor incision for FUTwill be closed with staples and/or sutures. Both absorbable and nonabsorbable sutures may be used. Superficialcrusting, pinkness, or redness of the incision area may occur, but these effects are usually temporary. Rarely, somearea of skin around the suture edges may be lost and this will cause deep crusting which will take longer to heal. Astretched, widened scar is possible, as is a thickened or raised scar (hypertrophic/keloid). Significant scarring is more likely to occur in people who have had a history of the above type of scarring or who have had previous transplantstaken from the donor area.
______HAIR LOSS: There may be temporary hair loss in the back of the scalp in the area of the harvested hair. Thishair will generally grow back. In the transplanted area, you may experience shedding of your existing hair followingthe surgery (a process called telogen effluvium). If this hair is at or near the end of its normal life span (miniaturizedhair), it may not return. Because genetic balding is a continuous process, you may continue to lose more hair overtime. If this occurs, a subsequent hair transplant procedure may be desired.
______ HAIR TEXTURE CHANGES: When your new hair begins to grow it may be more kinked or wavier thanyour original hair. Over time the hair generally resumes its normal character. It is possible that these hair texturechanges may persist.
______ FAILURE OF TRANSPLANTED HAIR TO GROW: As in all surgical procedures results cannot beguaranteed. It is possible that some or all of the transplanted hair may fail to grow. Every effort will be made to giveyou the maximum yield from your transplanted hair. I acknowledge there are no guarantees as to the outcome of thesurgery/procedure and/or need for additional medical and/or surgical treatment.
______ NUMBNESS AND PAIN: Numbness of the scalp/face may occur due to necessary cutting of fine nerve fibersin the skin. This is expected to gradually disappear over several months, but it is possible that all of the sensations maynot return. Rarely nerve injury may occur, resulting in long term or possibly permanent numbness and/or pain in thescalp.
______ SMOKING: Smoking causes constriction of blood vessels and decreased blood flow to the scalp,predominantly due to its nicotine content. The carbon monoxide in smoke decreases the oxygen carrying capacity ofthe blood. These factors may contribute to poor wound healing after a hair transplant and can increase the chance of awound infection and scarring. Smoking may also contribute to poor hair growth. The deleterious effects of smokingwear off slowly when one abstains, particularly in chronic smokers, so that smoking puts one at risk to poor healingeven after smoking is stopped for weeks or even months. Although it is not known exactly how long one should avoidsmoking before and after a hair transplant a common recommendation is to abstain from 1 week prior to surgery to 2weeks after the procedure.
______ SUN DAMAGED SKIN: After your transplant, you must still protect your scalp from the damaging rays ofthe sun. Your new hair makes close observation of your scalp important because unusual new skin growths, or skinchanges, may be more difficult to see. In addition, if you have a history of skin cancer or sun damaged skin, youshould be followed by your dermatologist. It is possible that significantly sun damaged skin may hinder hair growth.
______ INFECTION: The symptoms of infection include swelling, redness, tenderness or pus at the surgical site andmay be associated with fever or chills. If you experience any of these symptoms, contact us at once.
______ OTHER: There may be temporary swelling, discoloration, or bruising associated with the procedure. Theremay be the formation of a cyst at a graft site, ingrown or buried hairs, hematoma (localized blood clot), or rejection of a graft. In areas of scar tissue, grafts may grow poorly or not at all.
______ I am aware that, in addition to the risks specifically described above, that there are other risks such as loss ofblood and infection that may accompany any surgical procedure, as well as injury to nerves which may lead to partialnumbness. I realize that common to any procedure is the potential for infection, blood clots in veins and lungs,hemorrhage, allergic reactions and even death. I also realize that the following risks and hazards may occur inconnection with this particular procedure:
______ Unsatisfactory appearance/ unmet expectations
______ Creation of additional problems such as poor healing, skin loss, or painful or unattractive scarring.
______ Blood collection under skin (hematoma) requiring removal
______ I recognize that during the course of the operation, unforeseen conditions may necessitate additional or different procedures than those set forth above, including terminating the procedure at any point. I therefore furtherauthorize the above named doctor or his designated assistants to perform procedures as are in his professionaljudgment necessary and desirable.

C. For patients who have had prior hair restoration surgery at another institution:
______ I acknowledge that prior to contacting ERC, I received Hair Transplants/Scalp Reductions from another physician and the results of these procedures may have been below my expectations. I further acknowledgethat ERC, and employees, bear no responsibility for my present condition. I also acknowledge that Ihave been informed that ERC physicians may not be able to correct my condition, although theywill attempt to do so. Donor scars through old scarred up donor areas will be wider than normal, and several of mygrafts that are transplanted into old scarred up recipient areas may not grow.

D. Anesthesia
______ Local anesthetics (lidocaine, bupivacaine) with Adrenaline (epinephrine) may have effects on many of thebody�s organ systems, including the heart. Such effects may include allergic reactions, irregular heartbeats, or even, inunusual circumstances, a heart attack, cardiac or respiratory complications, paralysis, brain damage, or even death. Such risks are uncommon with surgical procedures performed under local anesthesia. Patients on the type of heart orblood pressure medications called �beta-blockers� may be particularly sensitive to epinephrine. Some patients mayexperience a temporary light-headed episode as a nervous reaction to injections. This reaction may cause a drop inblood pressure and lead to fainting. This condition is easily and relatively rapidly treated.

E. Alternatives to Hair Transplantation Surgery
______ Alternative methods do exist in eliminating or masking baldness (i.e. hair flaps, prosthetic devices, or drugtherapy). I am fully aware of these alternatives and have chosen hair transplantation as the best solution.

F. Sedatives
______ You may be given sedatives which will be managed by the physician during your procedure to relax you andmake you more comfortable. The sedatives may include Valium or Halcion given orally and Versed administeredintra-muscularly. These medications can depress respiration in some patients. Your oxygen levels will be monitoredduring the procedure. If you are sensitive to these medications or have any respiratory problems, please let the doctorknow.

G. Driving Caution
______ I am aware that I will be given medications during and after the surgical procedure that may cause drowsinessand/or impair my judgment. I understand that I will not operate a motor vehicle, or dangerous machinery, or make anyimportant decisions the day of surgery or at any time while I am under the influence of these medications.

H. Informed Consent
______ I have had sufficient opportunity to discuss my condition and proposed surgery with Teamand all myquestions have been answered to my satisfaction. The procedure, its indications, risks and alternatives have beenexplained to me by my physician, and through the inquiry package, and the preoperative instructions. I recognize thatduring surgery unforeseen conditions can occur that may alter the course of surgery and necessitate deviating from theoriginal plan. This may include the transplantation of more or fewer grafts than scheduled. I hereby authorize andrequest the surgeon to use his/her professional judgment to complete the surgery in a manner that will produce the bestresults in the safest way possible. I have read and understand this consent for surgery. I have been given theopportunity, by my physician, to ask questions, and all of my questions have been answered to my full satisfaction.

Any objections have been noted or stricken and initialed by me.
______ This consent was read and signed by me while I was not under the influence of medications or other substances that can cause drowsiness or impair judgment.
______ I understand that Clinic�s team, does NOT adhere to advance directives (living wills).
______ I believe that I have adequate knowledge on which to base an informed consent to the proposed treatment.
______ I understand that Male or Female Pattern Baldness is a progressive disorder which may start at an early ageand progress throughout life. Therefore, I understand that the doctor has made his best estimate for my future patternbased on family history and other factors, but it is impossible to determine exactly how far it will progress. Therefore,I may require additional procedures if it progresses much farther than anticipated.
I further understand that it isimportant not to start these procedures at too young an age, or if starting young, to be very conservative in the hairrestoration process. I understand that if I am losing hair slowly, it is best to replace my hair slowly (over a few years tomatch the rate of natural hair loss).
I agree to work with the doctor in locating the hair lines or other factors according to his advice so it will not be toolow or in an inappropriate place. I understand that the interval between hair transplant procedures is usually 8-18months. This is to allow time for the skin to remodel and smooth itself, and for hair to grow out. Healing rates vary, somy interval could be more or less. Usually, 1-3 transplant sessions are needed in any one area, depending on thedensity I desire. For example, 1-3 sessions are needed for the hairline, the top, and the crown. However, hair line, top,and crown may be transplanted simultaneously. I further understand that, as hair loss progresses, future touch-upsessions may be needed to fill new areas of hair loss surrounding the previous transplanted area. I acknowledge thathair restoration is an art form, and thus cannot be properly judged until it is completed. Therefore, I agree that I willnot achieve final results until I have completed ALL of my treatment plan, including any additional procedures I mayrequire for touch-up or additional hair loss on my part, and the hair has all grown for 1-2 years. I understand that theaverage treatment plan is 1-3 session in each area depending on the density desired.

I. Surgically Removed Tissue
______ Any tissue surgically removed will be disposed of in accordance with customary practice.

J. Patient Responsibility
______ I understand that it is my responsibility and I have arranged for a responsible adult to drive me home andremain with me following my surgery. I acknowledge that I have been advised by facility personnel not to drive untilall effects of medication have worn off. I understand this to mean that I should not drive until the day after mysurgery/procedure or as directed by my physician.
______ I understand that I am to leave valuables at home and acknowledge that I have been advised by facility personnel to do so. I release the facility from any responsibility for loss and/or damage to money, jewelry or othervaluables I brought into the facility.
______ I understand that if I am pregnant or if there is any possibility that I may be pregnant, I must inform thefacility immediately since the scheduled operation/procedure could cause harm to my child of myself.

K. Hair Transplant Planning and Incision Confirmation ( will be filled out by Teamthe day ofsurgery )
______ I approve of the hairline design and proposed follicular unit graft placement areas that were created by the team and I, as roughly diagramed above. I was involved in the design of the hairline and designating the areas to be transplanted. I have been given the opportunity to make any final adjustments.
Preoperative photographs were taken to document the design. ______ I approve of the incisions that will be made in my scalp as marked in the above diagram to obtain the donor hair. Every time an incision is made in the human body, a scar will occur, although every effort will bemade to make the scar as inconspicuous as possible. The donor incision will be closed with sutures and/orstaples. A stretched, or widened scar is possible, as is a thickened or raised scar (hypertrophic/keloid).
Significant scarring is more likely to occur in people who have had a history of the above type of scarring or whohave had previous incisions and/or hair transplants made in the donor area.

L. Cooperation
______ I agree to keep Teamand his staff informed of any change in my permanent address, and I agree tocooperate with them in my post-operative care. I hereby authorize the clinic�s team, aided by such assistants, photographers,or technicians as he may engage for this purpose, to take full face and scalp photographs and/or videotapes of me as hemay desire before, during, and after the operation which is to be performed on me for medical records purposes. Irelinquish all right, title, and interest in these photographs/videotapes to the clinic. I should understand thatphotographic documentation for medical purposes is the purpose of the photographs.
______ I have been given the opportunity to ask questions about my condition, alternative forms of anesthesia andtreatment, the procedure to be used, and the risks and hazards involved, and I believe that I have sufficient informationto give an informed consent.
______ In the event of any accidental exposure of any blood or bodily fluid to a physician, contractor, or employee ofthe facility, I consent to testing for HIV and Hepatitis
______ I understand that in the rare event that hospitalization is required during or immediately after the surgery, myphysician will arrange for my transfer to a local hospital.

PLEASE READ ALL THE PARAGRAPH FORTH ABOVE. WE WILL HAVE YOU SIGN BELOW ON

THE DAY OFSURGERY:  

I, , hereby declare that I agree on the placement and design of the HAIRLINE/FACIAL HAIR TRANSPLANT (_________________), which doctor has designed for me before proceeding with my Hair Transplant Surgery. In this regard, I am granting the Hair transplant staff of the permission to begin with my surgery and that I have no objections regarding the procedure that I will be undergoing.