I, the undersigned __________________________ acknowledge that I have visited Dr. Issam Zuhir Alachkar in his clinic and was suffering from: __________________________

I authorize Dr. Issam Zuhir Alachkar to perform the following actions: __________________________

Which is related to my case considering that the full information about the surgery has been clearly explained:

I declare that I know and understand that the goal of nose prosthesis is to achieve as much improvement as possible and that perfection is not guaranteed.

I was also informed that I would probably need subsequent operations or procedures after the first operation to reach satisfactory results.

I declare that the doctor explained the following points to me:

1- The process of wound healing and restoration varies from person to person and that sepsis, fibrosis, scarring, irregularity, grooves, compression, withdrawal, collapse, deviation and keloid can all occur due to wound repair and contraction and have nothing to do with the surgeon's skill or surgical technique.

2- Living skin and tissues do not resemble wood or marble, so living tissues can expand or contract, beyond the control of the surgeon.

3- The surgical technique may require an external incision of the skin that is likely to leave a permanent scar.

4- The surgeon may need to use a cartilaginous or bone graft from other areas of my body or an artificial graft.

5- Rarely, respiratory obstruction may occur and may require medical or surgical treatment later.

6- The goal of my functional nose surgery is to improve my nasal respiratory tract, but postoperative nasal secretions and sensitization can continue.

7- Rarely, bleeding, tendon perforation or adhesions may occur.

8- Rarely, surgery of the sinuses and adjacent structures may complicate.

I understand and accept these points.

I also allow the surgeon to keep my photos and use them for media, educational reasons or scientific research.

I also acknowledge and declare that the doctor has explained to me that complications of surgery and anesthesia that can occur are rarely dangerous, and I am fully convinced that the surgeon and the anesthetic will do their best and every effort to provide the best medical care and management as required by my condition.

Finally, I have read and understood everything written with this consent and authorize the surgeon and anesthesia to perform the surgery and anesthesia required for my case, and I acknowledge that I have been given papers explaining the postoperative instructions that I will take.

Patient's name and signature __________________________

Witness __________________________