Terms and conditions

NFORMED CONSENT FOR BARIATRIC SURGERY

(To be retained in the patient’s records)

Laparoscopic Bariatric Surgery, VSG, Bypass, Lap-band, Revision Surgery, Abdominal Hernia Surgery or any other Bariatric Procedure or Revision including gallbladder removal.

If you agree with everything stated in the paragraphs below, please initial each page and sign the document twice where stated. You, as the patient are asked to carefully read this document which is legal and binding. It is intended to ensure that you are completely informed regarding the nature and specific details of the surgical procedure to be performed, as well as potential risks and benefits involved.

I, Patient, hereby acknowledge having researched the surgery I am about to undertake. I have viewed and studied comprehensive detailed descriptions and information as well as possible issues related to Bariatric Surgery. I understand that bariatric surgery carries risks and I have done as much research as possible to help me understand these risks. I hereby agree to let any staff member from Dr. Juan Francisco Hidalgo’s office or the NewCity Hospital search my luggage and confiscate any item they deem necessary so that I do not eat or drink anything post-op that I am not supposed to.

RISKS OF OBESITY SURGERY: I recognize that I am severely overweight and meet the criteria for weight loss surgery established by the National Institutes of Health. I understand that this level of obesity has been shown to be dangerous, unhealthy, and to increase my risks of death from a variety of medical illnesses including diabetes, high blood pressure, heart disease, stroke, arthritis, cancer, sleep apnea, and lung disease. I also understand that my risk of death is significantly higher than non-obese individuals.

The reason I have chosen to undergo surgery is to help me lose weight so that I can reduce my risk of developing these and other diseases, potentially rid myself of these above mentioned diseases if I suffer from them now, and/or increase my chances to have a normal life expectancy.

It is important that you understand the risks, complications, and changes that may occur with weight loss surgery.

Please verify your acceptance of these risks at the end of the list.

Bleeding and the potential need for blood transfusion. Blood transfusion carries the risk of infection with bacteria, parasites, and viruses (Hepatitis, HIV/AIDS)
Infection or abscess
Chronic pain or discomfort
Numbness
Burning or tingling in the incision site or anywhere else in the body
Incisional hernia
Internal hernia
Bowel obstruction/strangulation
Atalectasis or lung collapse causing fevers
Pneumonia or lung infection including abscess
Deep vein thrombosis (blood clot in the vein)
Pulmonary embolus (blood clot going to the lung – fatal 30% of the time)
Stroke
Heart Attack
Injury to an abdominal or pelvic organ/structure
Nausea or vomiting
Dysphagia
Diarrhea or constipation
Heartburn or reflux symptoms
Ulcers and/or Gastritis
Conversion to an open surgery
Failure to lose adequate amount of weight
Loss of too much weight
Development of malnutrition or vitamin deficiency
Anemia
Development of food intolerance’s
Pressure ulcer or decubitus
Rhabdomyalysis (breakdown of muscle in the body)
Pancreatitis
Kidney failure and/or need for dialysis
Need for ICU care
Need for a ventilator
Death
Development of loose or redundant skin
Foul smelling stool and/or gas
Need for further or additional surgery to repair a problem
Prolonged hospital stay may be needed to treat complications
Allergic reaction to medicine/material
Reaction to anesthetic
Dumping Syndrome
Hair loss or thinning
Loss of taste
Nerve or ligament injury from positioning or lying on the operating table
Increased ability to become pregnant
Birth defects or fetal injury if I become pregnant. This is less likely once my weight has stabilized and my laboratory tests are normal. Usually about 2 years after surgery.
Organ Failure
Metabolic bone disease (loosing calcium from the bone because of inadequate intake and supplementation) with possible osteoporosis, secondary hyperparathnyroidism, bone fractures.
Need to revise or reverse the procedure at some point in the future because of nutritional deficiencies or excessive weight loss or other reasons.
Extended disability, financial hardship as a result of complications related to weight loss or surgery.
Band slippage
Band erosion
Obstruction from the band
Band or Balloon breakage
Need for further or additional surgery to repair a problem, or to repair, replace, or remove the Band.
Development of a dilated esophagus or “pseudoachalasia”
Dysphagia (difficulty or pain with swallowing)
Port dislocation, malfunction, leakage, flipping, or disconnection
Stricture
Post operative depression or other psychological reaction to the surgery
FOR PATIENTS WITH LUPUS: There is an increment in the risk of infection (by 50%) in the area of the surgery and all areas affected by the surgery, as well as dehiscence of the sutures and wounds either immediately or in the future.

Also, I understand that if I do not follow my doctor’s pre-op instructions, my medical tourism surgery insurance may be denied by the provider. By not following the pre-op instructions, I assume this risk.

Weight Loss Options: I understand that there are many options for weight loss. I certify now that I have tried my best to lose weight using dietary and exercise regimens and have been unsuccessful despite many attempts. I have been informed that weight loss surgery should only be considered as a last resort and after all other non-operative methods have failed. Just as there are many different types of diets, there are also different types of procedures to lose weight. I acknowledge that I am thoroughly aware of my options for surgical weight loss including the advantages and disadvantages of each procedure. I have reached the decision regarding which surgical weight loss procedure is right for me after extensive personal consideration, and have no reservations about my decision at this time.

Acceptance of Surgery: I affirm and understand that the field of weight loss surgery is filled with controversy and that some medical professionals believe that surgery is not appropriate under any circumstance for weight loss. I also understand that long term data on the outcome of surgery for weight loss may be incomplete or inconclusive, but at this time most physicians as well as the National Institute of

Health believes that for patients who are considered “Morbidly Obese” and have failed dietary and exercise measures, surgery is the best option for significant and long-term weight loss.

“minimally invasive” approach (either Laparoscopic or Hand-Assisted). I have intentionally chosen this approach because I believe it will cause less pain and scarring, and allow me to leave the hospital quicker. I understand that these techniques are more difficult for my surgeon to perform, and as such, there is a small possibility that it will not be possible to perform my surgery laparoscopically. I am willing to accept the possibility that my surgery will need to be performed “open” using a large incision causing a larger scar, more pain, and a longer hospital stay and recovery time. I also agree to pay the additional fee of $2,000 US dollars in the event the surgery needs to be converted to an open procedure.

Risk of Surgery: I understand that surgery contains risks and complications can occur. I also understand that all surgeons have complications no matter how skilled or talented they are. I understand that by being obese, my risks during surgery are higher than the average person, and that most complications that occur are due to that fact. I have been advised about the extensive and comprehensive risks regarding the complications that are possible during my surgical procedure or as a result of the procedure.

I have had the opportunity to ask questions and clarify anything that was not completely clear and/or understood by me. In addition, I was given a listing of potential complications, which I have read in its entirety and fully understand. I am fully aware that if a complication were to occur either during or after surgery, it is my full responsibility to pay for any costs or fees associated with the complication. The amounts are unknown at this time but I hereby agree to pay for any and all costs or fees of any complication arising from my having weight loss surgery.

Blood Transfusion: I understand that surgery can be associated with a significant loss of blood. If this occurs, I realize that I may need to undergo a transfusion of blood products including coagulation factors, platelets, and/or red blood cells. Despite the fact that blood products and donors are screened, infection with bacterial or viral particles is possible from these products. In addition, I understand that transfusion reactions can occur due to antibodies that my system may produce to blood from another individual. I certify that I understand these risks and will accept the transfusion of blood products if my doctor feels they are medically necessary.

Hernia and other procedures: If it is deemed that I have a hernia I consent to the repair of the hernia during surgery. I also consent to any procedure the doctor deems necessary to save my life during this procedure and I hereby agree to pay for the costs related to these procedures.

Revision Surgery: If you have had a lap band, or it has been removed, a prior sleeve or bypass surgery, or any other abdominal surgery, then your current surgery you are having is considered revision surgery.

Revision surgeries can end up costing more than the stated price of the surgery due to unforeseen factors like extra time in the operating room, extra medication, complications and other factors. You hereby agree to pay the hospital directly and prior to discharge, for any additional costs associated with the current surgery taking place and acknowledge the fact that these costs are unknown prior to surgery but may arise due to the fact that the surgery is considered a revision surgery.

Compliance: I agree to abstain from alcohol and tobacco use, attend support group meetings, attend scheduled follow-up visits, and maintain recommended dietary and exercise regimens. I agree to take every precaution to avoid pregnancy until approved by my physician(s) which may be as much as two years or more after surgery. I understand that even if I have fertility problems in the past, weight loss may make me more fertile requiring birth control during the initial two years after surgery.

Limited Liability and Waiver thereof: Hidalgo Bariatrics®, its staff, employees, agents, promoters, representatives, are not responsible or liable for any advice, course of treatment, diagnosis or any other information, services or products that you have obtained. I have further been informed that all staff members, representatives, agents, promoters, and/or employees, have nothing to do with the actual procedure of weight loss surgery; all staff members, representatives, agents, promoters, and/or employees only provide a reference and I hereby fully agree to hold any Hidalgo Bariatrics® staff members, representatives, agents, promoter, and/or employees, other than the actual surgeon, either in whole or in part, free from any and all liability associated with my undergoing surgery with Dr. Juan Francisco Hidalgo, or the hospital that the procedure is done in. I fully accept this waiver of liability by placing my initial on this page or anywhere else in this document.

Disclosure Statement: I hereby agree to indemnify and hold harmless Hidalgo Bariatrics®, its staff, employees, agents, promoters, and representatives, against any and all liability, claims, suits, losses, costs, and/or legal fees caused by, arising out of, and/or resulting from any negligent act or omission in the performance and/or failure to perform by Dr. Juan Francisco Hidalgo or the NewCity Hospital, anyone on their staff, under their control or anyone associated with the procedure at hand, or the hospital and its staff and/or anyone under their control. The information provided by Hidalgo Bariatrics®, its staff, employees, agents, promoters, and representatives, is intended to be a general guide only and its content should be discussed with your local medical practitioner. Hidalgo Bariatrics®, its staff, employees, agents, promoters, and representatives, shall not be liable for any loss caused, whether due to negligence or otherwise arising from the use of or reliance on any and all information provided including the website in general and/ or as a whole. I fully accept the above, by placing my initial on this page or anywhere else in this document.

Photographs/Observers: I agree to allow intra-operative, pre-op and post-op photos or video to be taken of myself or the procedure, which is being performed on me. I agree that these photos/videos may be used for any educational, marketing, scientific or medical purpose. I waive my rights to these images or to compensation for these images. I agree to allow other health care personnel or representatives of surgical or equipment companies to be present in the operating room if requested by my doctor(s).

Any images sent or posted to any of Hidalgo Bariatrics® social media, email or website of Hidalgo Bariatrics® post-op is covered and included under this paragraph and all rights to these images are transferred to Hidalgo Bariatrics® and no compensation will be received.

Reproductions: I agree that this form, when signed by me, this document is a legal and binding contract and/or document. Digital reproduction and/or Xerox or Fax copies are considered the same, and are as enforceable as the original Law: I agree that only the laws of the state of Baja California/Jalisco, located in the Country of Mexico, govern this agreement.

Arbitration: I agree to binding arbitration to settle any medical and or legal disputes and herby waive my right to a jury or court trial for this purpose. I hereby agree that Arbitration will occur in Tijuana, Baja California Mexico, using Mexican Laws, and Mexican Lawyers and I waive any and all of my rights to any legal, or judicial proceeding in the United States, or anywhere else in the world, even if I am not aware that any rights are entitled or available to me.

Results of Surgery: I have not been given any promises or warranties regarding the outcome of/or results of my surgery. I have been given guidelines, outlining results and expectations. I understand that my results will vary and depend on many factors and variables and my results may or may not fall within the guidelines and expectations discussed.

Post Surgery Instructions and Follow up: I also understand that I may cause complications or have an unacceptable result if I do not follow my doctor’s instructions and post-op diet after the surgery or fail to take the necessary medications, nutritional supplements or vitamin supplements. I also understand the importance of regular follow-up with my surgeon and notifying him if I am having any problems at any time after surgery. I realize that the ultimate success of this surgery is dependent not only on the procedure itself, but more importantly, to the changes that I make in my lifestyle and diet. To this end, I agree to follow my surgeon’s recommendations and instructions to include dietary and activity limitations, nutritional supplements, attending support groups and return/follow-up visits following surgery.

I agree to abstain from tobacco and minimize the use of alcohol. Where applicable, I agree to use birth control to prevent and control pregnancies for at least 18-24 months post-surgery. I also agree to participate in On-line chat/support groups, at least monthly as part of my overall weight loss program.

Health Maintenance Statement: I have been counseled on the importance of comprehensive preoperative screening and health maintenance. These tests may but not necessarily include but are not limited to chest x-ray, electrocardiogram, laboratory blood panel, mammogram, pap smear, bone densitometry, endoscopy, colonoscopy, abdominal ultrasound and pelvic ultrasound.

Financial hardship: I understand that if I choose to undergo this surgery outside of my insurance company (without their authorization or as a “self pay patient”). I may incur financial hardship and significant debt if I sustain a complication or have any problems following surgery. I realize also, that any complication that arises in the future will also be my responsibility and that my insurance will not cover these problems either (if the surgery is performed outside my medical insurance). I also realize that even if my insurance authorizes the procedure, they may only cover a portion of the total cost and I will be responsible for the balance. I hereby authorize and agree to pay any and all additional costs associated with any complications that arise out of my procedure. By signing this document, I agree to allow the doctor or his assignees to proceed to collect any outstanding amounts that may arise from any complications in any and all manners that they see fit, either in the United States or Mexico.

Extra Charges: I fully understand that I am having surgery and there are unknowns with any type of surgery. I have been given a pre-op diet to help me prepare for this surgery. During surgery, there may be extra charges that occur either from a complication or due to lack of preparation for surgery or even just extra material that has to be used, or even broken medical equipment due to high BMI. I hereby agree to pay for any and all extra charges billed by the hospital due to me having surgery here in Tijuana with Dr. Juan Francisco Hidalgo. These extra charges may be for any legitimate reason including but not limited to, a hiatal hernia repair, extra staples used for surgery, broken instruments that bend due to the surgery procedure and positioning of the high BMI body during surgery, or any other expense charged by the hospital during my surgery that is not covered under the surgery package. I also agree to pay for any expenses incurred extra for medication administered not within the surgery package and I hereby agree to pay for all of these expenses so long as I am provided with a receipt prior to my departure from the hospital and before I leave Tijuana.

FAILURE TO COMPLETE SURGERY: I understand that surgery carries many risks and at times it is impossible for the doctor to complete the surgery I have travelled down to have. I understand that there are hospital fees and medical fees involved with any medical procedure and I agree that once I register and arrive at the hospital, I will be billed and agree to pay for any and all medical fees, hospital fees, specialist fees or any other reasonable fee generated by my admittance, even if the original surgery is not performed for whatever reason.

EPIDURAL ANESTHESIA – the surgical team offers two types of anesthesia, general anesthesia or general anesthesia combined with an epidural. General anesthesia combined with an epidural has been proven in past patients to provide better results for post-op recovery, less nausea, and less pain.

That said ultimately every single patient has the opportunity to decide which type of anesthesia they want applied and you hereby are notified that you have a choice of which you prefer. By having surgery, with Dr. Juan Francisco Hidalgo, you have agreed before surgery which anesthesia approach will be provided. You always have a choice as to which type of anesthesia you want.

STAPLE REMOVALS: As a courtesy, Dr. Juan Francisco Hidalgo or a hospital doctor will try to remove your surgery staples before you go home. Sometimes the staples require a longer time in place and as a result, you may have a wound that may open a little after the staples are removed. Please use steristrips on these wounds and there is a risk that the scar will be a little larger or uglier than normal.

SPECIAL NOTE FOR PATIENTS WITH HEPATITIS AND INFECTIOUS DISEASES: Please note that Dr. Juan Francisco Hidalgo is willing and able to undertake your surgery if you have an infectious disease such as HIV or even Hepatitis. Please note that the hospital charges a special cleaning fee after each of these surgeries that are not anticipated in the surgery price provided. Also, additional special medical supplies may be used. You hereby agree to pay for these extra costs that range from $100usd to $500usd. Once surgery has been completed and the hospital has provided the final bill for the surgery including these Extra costs. Dr. Juan Francisco Hidalgo or a staff member will go over the final cost with you after surgery before hospital discharge.

Having read this form in its entirety, my signature below acknowledges that I agree with and understand all of the statements and materials contained and set forth within this document. I am aware of the many risks of surgery, especially weight loss surgery, and I fully understand them and accept these risks. I hereby also have read prior to my surgery and agree to, all of the terms and conditions set out on the legal page of www.hidalgobariatrics.com