I have elected to have vaginal aesthetic surgery for the following reasons(patient: Write in your own words here):

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I understand that these procedures are designed to help eliminate symptomatic “bulges” from the vagina, and/or improve the appearance   and/or “size” and “tone” to the vagina

In all likelihood my goals will be accomplished. However, I understand that the following may be unexpected outcomes of my procedure(s)

• Complications including but not limited to: a). infection,  b).  hematoma, abscess,  c).injury to an adjacent organ which could produce a “fistula”,  or excessive loss of blood which may lead to the necessity for other procedures to control bleeding and/or repair the injury, d) delayed or incomplete healing, e). prolonged postoperative  pain, or other rare events.
• Under-tightening or over-tightening, leading to the necessity of several weeks “stretching” the vagina prior to being able to engage in vaginal intercourse.
• Cosmetic results not up to my expectation

I understand  that  Dr.  Abovyan David will perform surgery carefully and make every effort for results up to my expectations, but that these results cannot be guaranteed.

In my own words, this is what I expect Dr. Abovyan David to do:_____________________________________________________________________________

Also, I hereby give Dr. Abovyan David permission to take  “Before and after” photographs.

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Patient

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Date

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