Informed Consent for Gender Affirming Surgical Procedures

Procedure Name

Form Sections

Section 1info grid

Surgical Facility Name

Attending Plastic Surgeon

Patient Full Legal Name

Preferred Name (Optional)

Date of Birth

Medical Record Number (MRN)

Planned Gender Affirming Procedure

Section 2text block

Section 3list block

Section 4text block

Section 5list block

Section 6text block

Section 7text block

Section 8text block

Section 9text block

Section 10text block

Section 11text block

Section 12signature block

Patient / Authorized Representative Signature

Witness Signature (If Required)

Attending Surgeon Signature

Informed Consent for Gender Affirming Surgical Procedures

Patient and Facility Information

Surgical Facility Name

Attending Plastic Surgeon

Patient Full Legal Name

Preferred Name (Optional)

Date of Birth

Medical Record Number (MRN)

Planned Gender Affirming Procedure

Nature and Purpose of the Procedure

This document records informed consent for gender affirming surgery. The surgical procedure, which is intended to align physical characteristics with gender identity, is performed under general anesthesia. The attending surgeon will discuss the specific surgical methods (including scar placement, tissue reconstruction, and implant options if applicable) prior to the procedure. The goal is to support the patient's therapeutic plan.

Material Risks and Potential Complications

Bleeding, hematoma formation, or seroma collection, which may require aspiration or surgical drainage.

Infection or poor wound healing (wound dehiscence), potentially leading to prolonged dressing changes or skin graft needs.

Loss of sensation, numbness, or changes in skin sensitivity (including nipple-areola complex sensation changes) in the treated areas, which may be temporary or permanent.

Asymmetry, contour irregularities, or unacceptable scarring, which may require secondary revision surgery.

Partial or complete loss of tissue grafts (including nipple grafts or skin flaps) due to compromised blood flow.

[Insert additional procedure-specific risks as discussed with the surgeon here]

Expected Benefits

Expected benefits include alignment of physical anatomy with gender identity, reduction in gender dysphoria, and overall improvement in psychological well-being and quality of life.

Reasonable Alternatives

Non-surgical management options, including hormone therapy, social transition, or professional psychological support.

Alternative surgical techniques or delaying surgical intervention.

Choosing not to undergo gender affirming surgical procedures.

Consent for Anesthesia Services

I understand that anesthesia services are needed for this procedure. The anesthesia provider will separately explain the risks, benefits, and alternatives of the specific anesthesia plan (e.g., general, regional, or local sedation) and obtain separate consent.

Consent for Blood Transfusion

I understand that during this procedure, significant blood loss may occur. If my physician determines it is medically necessary to preserve my life or health, I consent to the administration of blood or blood products.

Tissue Disposal and Pathology

I authorize the medical facility to retain, preserve, use for educational purposes, or dispose of any tissue, fluid, or body parts removed during the procedure in accordance with standard medical practices and legal requirements.

Photography and Observer Consent

I consent to the photographing or video recording of the procedure for medical, scientific, or educational purposes, provided my identity is not revealed. I also consent to the presence of medical students, residents, or device manufacturer representatives as approved by my surgeon.

No Guarantees

I acknowledge that the practice of medicine and surgery is not an exact science. I understand that no guarantees or assurances have been made to me regarding the outcomes or results of this procedure.

Patient Acknowledgment and Consent

I certify that I have read and fully understand this consent form. My physician has explained the procedure, its risks, benefits, and alternatives. I have had all my questions answered to my satisfaction, and I voluntarily consent to the proposed treatment.

Signatures and Verification

Patient / Authorized Representative Signature

Witness Signature (If Required)

Attending Surgeon Signature

Document ID: CC-PENDING

CONSENTCOLLECT