RHINOPLASTY CONSENT FORM

The e-booklet below is both the Rhinoplasty consent for surgery and the Terms and Conditions of Berkeley Square Medical. Though you will have received hard copies of the exact information below at the time of your first consultation, it is important you re-read this fully and sign at the bottom of the page.

A Rhinoplasty or nose job is a surgical procedure performed to reshape the nose. It is the most individual of all aesthetic surgery procedures requiring the most dexterity, skill and understanding of the patient’s wishes, the technical possibilities and the underlying anatomy. There are several different ways of performing Rhinoplasty surgery and the exact way is very dependent on how the surgeon best thinks it is possible to achieve the aims of the patient.

Of all the surgical procedures we perform as Plastic Surgeons, a Rhinoplasty is considered one of the most complex. A Rhinoplasty can be performed with all the surgical incisions on the inside of the nose, or with some on the skin; it can be performed with or without using cartilage or bone grafts; it can be performed for breathing difficulties and can also be performed completely non-surgically using injections of skin fillers to fill out some of the nose skin to hide minor imperfections in the nose.

If you are considering a Rhinoplasty, you will want to know the following information about nose reshaping surgery.

Before you have a Rhinoplasty, your surgeon will assess your nose. You will need to say what you would like to achieve, what you do not like about your nose and how it affects you personally. It is important to be very honest about this and being very specific is helpful to your surgeon.

Your surgeon will ask you about your general health and whether you have any previous relevant issues with your nose (operations, injuries, breathing difficulties, allergies etc). The examination involves looking and feeling the nose internally and externally along with a breathing assessment. Your surgeon will also have a look at the skin of the nose and will assess the size and shape of the rest of your face. Most patients are looking for a nose that is in proportion with their facial features. If, for example, the chin is too small, this may give the nose an apparently prominent appearance of the face. So, sometimes your surgeon may talk about other additional procedures.

To perform a Rhinoplasty, your surgeon needs to access the cartilages and bones that form the structural framework of the nose. Together, the cartilages and bones form the skeletal support of the nose, and a Rhinoplasty changes these structures. Your skin then re-drapes across the new framework.

A “Closed Rhinoplasty” is one in which the incisions are made on the inside of the nostril, and an “open Rhinoplasty” is one in which a small incision is made in the skin under the tip of the nose which separates the two nostrils. Some surgeons do more open Rhinoplasties, as they feel they can predict the final outcome more readily, but other surgeons do more closed Rhinoplasties as the final result is achieved with less swelling and a shorter recovery period in a procedure that is already associated with a long recovery period before the final results are seen.

Whichever method is used; the surgeon will reshape the bones and cartilages and expect the skin to re-drape over the new shape without too much swelling. If the skin is too thin, then any minor imperfections may be more noticeable, and if the skin is too thick, then the skin may not drape well across the new shape of the new skeletal framework.

1. Your desired outcome of changes to the shape/size of your nose to a proportionate result.
2. A result that takes the focus away from your nose as opposed to placing attention to it.
3. A nose that is more proportionate to your face.
4. You to be happy with the outcome of your surgery result.

As with all surgeries, both cosmetic and medical, surgery will always carry elements of risk that we hope not to see. In Rhinoplasty surgery, these risks include infection, abnormal bleeding and swelling, over and under-correction, cartilages and bones moving after they have been reset in a particular position, asymmetry and healing problems.

Some of the risks are related to the function of the nose and include breathing difficulties, nasal drips and nose bleeds.

Your nose also continues to grow throughout your life so it will slightly change shape in later years of your life.

Complications are most commonly seen in smokers and if you smoke, please stop smoking a few weeks before your surgery. If you take any nicotine alternatives, please stop using them a few weeks before your surgery.

As recovery progresses, we may see or feel slight dips and bumps in the nose, along the cartilages and the bones. These usually appear a few weeks after the Rhinoplasty and continue to settle over the recovery period. Sometimes they may remain and sometimes the minor dips and bumps reform and fully resolve. If these concern you, we can offer treatments such as fillers to smooth these out during your recovery while the contour of your nose settles.

The final results of a Rhinoplasty are not seen for about one year once all the internal swelling settles down. The final results take longer to achieve with some variations of a Rhinoplasty. For example, open Rhinoplasty and revision Rhinoplasty recovery times are generally longer. Though you may be pleased with your results a few days after your surgery, it is important to remember we expect a final result 12 months after full recovery, inclusive of internal healing, which may not be visible to you.

You will have nasal packs for a few hours and a blocked nose for several days after a Rhinoplasty. Bruised eyes last for around 5-7 days, but the tip and bony portion of the nose will stay swollen for several months after the operation, with the last of the swelling taking several months to resolve completely. In very rare cases, some people report permanent swelling or discoloration around the lower eyelids after a Rhinoplasty.

After your surgery, you may have a plaster (or nasal splint) and dressings placed on the nose, and may have stitches in the undermost part of the nose or on the sidewall of the nose, if you are having a particular type of Rhinoplasty. Stitches will usually stay in place for around 7-days. You may also have small incisions made on the side of your nose depending on whether the bones need to be reset and how this will be performed, and the scars associated with these usually settle to look like minor skin blemishes in the area.

Numbness, prominent veins developing on the nose, skin damage, impatience with the recovery process, dissatisfaction with the final result.

Cartilage and bone grafts are more common in secondary Rhinoplasty. Complications include the complications from taking cartilage or bone grafts from the rib, head or ear, such as scars, infections, bruising and swelling at the site of the graft. When grafts are inserted, we expect most, if not all, of the graft to survive but sometimes the graft is absorbed, and some or all the graft may not survive. Sometimes we see persistence of the abnormality in the nose and moving of grafts after they have been put into place. Secondary Rhinoplasty is associated with a longer recovery time, more swelling and less predictable results.

There is always a revision rate associated with Rhinoplasty and we aim for a revision rate for Rhinoplasty of less than 5%. The rate of revision in Rhinoplasty in the UK and USA ranges between 5% – 15%.

A recent 2024 audit of our last 900 Rhinoplasty Surgeries carried out at Berkeley Square Medical carried a revision rate of 3.0%.

It is important that you read your terms and conditions before proceeding with your relevant treatment/procedure. Terms and conditions are available on our website. They may also be provided to you at relevant opportunities including:

1. Confirmation of your first consultation booking sent via email.
2. Within our Patient Guide Booklet – provided as a hard copy to you at your consultation.
3. Within all correspondences for requests of payment E.g., Surgeon Consultation Bookings, Deposit Payments, Final Balance Payments, Treatment Payments.
4. Within your Confirmation of Surgery file sent via email.

 
DEFINITIONS AND INTERPRETATIONS
 In these terms and conditions the following words and expressions shall have the meanings respectively set against

“Consent Form” The consent form signed by the Patient consenting to the Relevant
“Treatment /Consultation” An in-person appointment with a Relevant Practitioner.
“Cooling Off Period” A stated amount of time in which a patient is not permitted to undergo their relevant treatment.
Medical Council.
“Non-Surgical Treatment “Treatment supplied by Berkeley Square Medical not being a surgical Procedure.
“Nurse” A nurse registered to practice by the UK Nursing and Midwifery Council.
“Patient” Any person who has entered or is contemplating entering into a contract for a Surgical Procedure or Non-Surgical Treatment with Berkeley Square Medical
“Patient Guide” The pack of information so-called to be provided to Patients by Berkeley Square Medical.
“Procedure” A procedure to be procured by Berkeley Square Medical for a Patient of a surgical nature to be performed by a Surgeon / Doctor.
“Readmission Policy” As set out in the Patient’s Guide relating to the re-admission of your surgical or non-surgical procedure
“Refund Policy” As set out in the Patient’s Guide relating to the refund of payments.
“Relevant Practitioner” A Nurse, Surgeon or Doctor (as the case may be).
“Relevant Treatment” The Procedure or Non-Surgical Treatment booked through Berkeley Square Medical carried out or to be carried out on the Patient by a Relevant Practitioner.
“Surgeon” means a medical practitioner being registered to practice with the General Medical Council.

1.0 – BERKELEY SQUARE OBLIGATIONS
In providing a Relevant Treatment for a Patient, Berkeley Square Medical shall:

1. Ensure all procedures are only carried out by a surgeon on the specialist registrar as a Plastic Surgeon with the GMC UK or International equivalent.
2. Ensure non-surgical Treatments are carried out by a Relevant Practitioner registered in the UK.
3. Perform all procedures and relevant treatments at facilities registered and regulated by the UK Care Quality Commission (CQC) UK.
4. Provide the patient with such information that can be reasonably expected to be necessary for the patient to understand the nature of the Relevant Treatment being offered together with the benefits and the risks and normally associated with such Relevant Treatment.

1.1 – PATIENTS OBLIGATIONS

1. The patient should be responsible for reading and understanding the Patients Booklet or information literature provided by us via print or digitally before and after their relevant treatment.
2. The patient should be responsible for reading and understanding any medical notes and consent forms provided during the journey of their surgery, from initial enquiry to the date of their relevant treatment.
3. Make payments on invoices as they fall due in relation to their relevant treatment.
4. Patients are responsible for ensuring they sign and submit medical assessments and consenting forms for surgery within the time frames specified.
5. Patients are responsible for arranging their post-operative appointments (except their first post-operative appointment). Berkeley Square Medical advises that any surgery performed by your surgeon is reviewed at approximately 3-months, and then as dictated by your surgeon for future appointments.
6. Patients are responsible for attending their post-surgery appointments and surgeon review appointments at the recommended times set out by their surgeon. Failure to attend surgeon review appointments will invalidate their aftercare that is provided as a part of their surgery/treatment.

  2.0 – RELATIONSHIP WITH RELEVANT PRACTITIONER

1. BSqM accepts no responsibility for matters which are covered within the professional responsibility of the relevant Practitioner or Doctor. All Surgeons and Doctors remain independent Medical Professionals.
2. The Relevant Practitioner is fully insured against claims for professional negligence on terms that BSqM reasonably considers are normal given prevailing market conditions at the relevant time with either the Medical Defence Union, the Medical Protection Society, or another appropriate Medical Insurance organisation.
3. The Relevant Practitioner holds the necessary qualifications and registration in the UK.
4. The Surgeon or Doctor is registered with the GMC (General Medical Council) in the UK.
5. Without prejudice to the generality of the above, the Surgeon or Doctor is solely responsible for deciding whether or not the patient is suitable for the Relevant Treatment.

3.0 – PAYMENTS POLICY

1. The patient shall pay the costs of their relevant treatment(s) at times when they fall due. BSqM Refund Policy shall apply to all such payments. All fees for the Relevant Treatment(s) shall be paid in accordance with any payment schedule agreed with the Patient on the dates stated in their payment schedule. Payments for Relevant Treatments are currently exempt from VAT.
2. Any late/delayed payments or breach in the payment schedule of the patient may result in cancellation of their consultation or relevant treatment. The administration cost to any decision made by BSqM to cancel a patient’s consultation or relevant treatment due to late payment is set out in our Cancellation Policy below.
3. All payments of £250.00 and above by credit/debit card must be paid by the patient undergoing the relevant treatment. Payments over £250.00 made by any cardholder other than the patient will not be accepted without prior approval.
4. Patients who wish to have their relevant treatment (any payments over £250) paid on their behalf by a 3^rd Party (E.g., Parent, Spouse, Partner Etc) must be made via Bank Transfer to BSqM.
5. Payments over £650.00 must be paid by Bank Transfer.

4.0 – RE-SCHEDULING POLICY
4.0.1 – CONSULTATIONS / SURGEON APPOINTMENTS
Consultations with relevant practitioners may carry a consultation fee. Upon booking a consultation, if you subsequently decide to reschedule that date, an administration fee may apply. In cases where a patient reschedules their booked consultation giving:

1. More Than 28 Days’ Notice from the Consultation Date and not less than 28 days from your consultation date is  –   NO CHARGE
2. Less Than 28 Days’ Notice from the Consultation Date: £50.00
3. Non-Attendance:  £100.00
4. All notices to reschedule must be emailed to info@berkeleysquaremedical.com.
5. These fees will be deducted from any payments already made towards the appointment or added to the cost of any rescheduled consultation.
6. Reschedule of your consultation must be rebooked within 28 days after the original consultation or it will be treated as £100 cancellation of your original consultation booking.

4.0.2 – PROCEDURES (SURGERY)
If your confirmation of surgery is booked or confirmed less than 14 days before your proposed date of surgery, the terms mentioned below remain applicable. Upon paying your deposit amount to confirm your surgery date, if there is a request to reschedule the original date, a rescheduling administration fee will apply. In cases where you reschedule your booked date for surgery giving up to:

1. More Than 30 Days’ Notice (from the Surgery date):                                                         £250.00
2. 29 Days until the Surgery date):                                                                                                      £1300.00
3. All notices to reschedule must be emailed to info@berkeleysquaremedical.com.
4. These fees will be added to the total operation fee and will be payable prior to surgery.
5. Please note: This policy is not affected by Berkeley Square Medical’s 14 days “cooling off period”.
6. If you subsequently cancel rescheduled surgery, then Berkeley Square Medical’s refund policy will be applied based on the rescheduled period in both rescheduled and cancelled dates.
7. If you reschedule your surgery more than once, the full balance of your surgery will be payable upon any subsequent confirmation of a rescheduled date.

 
4.1 – WHAT YOU ARE COVERED FOR: 

1. You are covered If you are deemed unfit or unwell on the day of surgery as indicated by our nursing team, Anaesthetist or Surgeon, your surgery will be rescheduled at no charge.

1. You are covered if you have been deemed unfit by another medical professional however, you are required to obtain a medical letter from that medical professional stating why you are unfit for your surgery.

1. You are covered should you test POSITIVE for COVID-19 via a Test within 14-days before your surgery date. You will, however, be required to undergo a second COVID-19 test at an additional cost (if App).
2. Unexpected death of a family member, spouse, civil partner or bereavement caused. You will be required to provide evidence of death. Coverage under this section will be at the discretion of Berkeley Square Medical.

4.2 – YOU ARE NOT COVERED FOR: 

1. Rescheduling your surgery due to being unfit for surgery caused by you not following pre-surgery requirements e.g., when you are advised to stop eating/drinking prior to surgery or taking certain medication for the day of surgery. This includes any restrictions or requests made by your surgeon at the time of your consultation.

1. Rescheduling your surgery due to failing to notify your surgeon of any pre-existing medical conditions that would deem you medically unfit to undergo your treatment at the time of your first surgeon consultation or within your medical assessment completed prior to your first appointment with your surgeon.

1. Rescheduling your surgery should you become pregnant prior to your surgery.

1. Rescheduling your surgery due to an elective change in your decision to undergo your surgery.

5.0 – CANCELLATION POLICY
5.0.1 – CONSULTATIONS / SURGEON APPOINTMENTS
Consultations with relevant practitioners may carry a consultation fee. Upon booking a consultation, if you subsequently decide to cancel your consultation, an administration fee may apply. In cases where patient cancels their booked consultation:

1. Within 28-Days of your booking being confirmed and not less than 28-days before your appointment date: (Please See Refund Policy Section) – FULL REFUND
2. After 28-Days from your booking being confirmed (Cooling-off period): £50.00
3. Less than 28-Days from your booking being confirmed (Cooling-off period): £50.00
4. Non-Completion of your Medical Assessment: £50.00
5. 7-Days until the time of your consultation: £100.00
6. Non-Attendance / Non-Completion of your Medical Assessment: £100.00          
7. All notices to cancel must be emailed to info@berkeleysquaremedical.com.
8. These fees will be deducted from any payments already made towards the appointment or added to the cost of any rescheduled consultation.

NOTE: All new consultation patients will receive their online medical assessment form before their consultation date. Medical Assessments must be completed and submitted within the stated time. Failure to submit Medical Assessments within the specified time may result in automatic cancellation of your consultation. 
 
5.0.2 – PROCEDURES (SURGERY)
If you cancel your surgery, or due to late payments, your procedure has been cancelled by BSqM, any consultations fees are non-refundable. Berkeley Square Medical will also charge or retain the following administration costs if cancellation is within the following time periods:
If cancellation of your surgery is:

1. 30 Days or more Before your Surgery Date: £400
2. 15 to 29 Days Before your Surgery Date:  50% of Total Surgery Fee
3. 14 Days or less Before your Surgery Date:  100% of Total Surgery Fee
4. All notices to cancel must be emailed to info@berkeleysquaremedical.com.

6.0 – REFUND POLICY

1. Completed Surgeon Consultations, Medical Imaging Services and any Pathology/Pre-Operative Tests are non-refundable upon completion.
2. If you originally paid the fees by credit or debit card, you will be refunded to the same card only.
3. If you originally paid by cash or cheque the refund will, in both instances, be refunded via a bank transfer.
4. All refunds are processed within 21 days from the agreement to any refund.
5. Refunds made to debit or credit cards carry a refund processing fee of 2.5% deducted from the refund amount.
6. Any refunds due which are not claimed within 12 months of the final payment will be forfeited.

7.0 – ADDITIONAL PRE-OPERATIVE TESTS
Any tests, investigations indicated by our clinical team or surgeon are not included in the cost of your surgery invoice. However, pre-operative requirements of MRSA testing are included in the cost of your surgery. Should you cancel your procedure, the costs of any tests or investigations will be charged at the applicable cost.

8.0 – POST-OPERATIVE CARE
Tests & Investigations – Any tests, Investigations indicated by a clinical team, within the first 28-day period following surgery, will be provided free of charge. Any care commenced during this period will be continued on this basis as deemed necessary by the clinical team and our surgeon.
 
Consultations & Reviews – Any follow-up consultations with your Surgeon are always included in the cost of your surgery. Should you request a subsequent review with your surgeon to repeat details previously discussed with your surgeon, a consultation fee will apply.

1. A cost of £50.00 will be payable if you fail to attend any of your post-operative appointments without giving at least 24-hour’s notice before the appointment date.
2. Post-operative review appointments with the clinic nurse or your surgeon will be provided in line with the post-operative care regime for your procedure, or as your recovery dictates. No further appointments are required unless clinically indicated by your surgeon.
3. Patients are responsible for arranging their post-operative appointments. Berkeley Square Medical advises that any surgery performed by your surgeon is reviewed at 3-4 months and thereafter as your surgeon dictates based on your recovery progress. All appointments are included in the cost of your surgery (excluding no-show/failure to attend appointment charges). All patients are advised to book 3-5 months in advance for Surgeon Post Operative appointments.
4. Review appointments with your surgeon will be provided in line with the post-operative care regime for your procedure, or as your recovery dictates. There will be a fee for surgical consultations outside of our readmission period which is 16-Months after your surgery date.

8.0.1 – ONLINE MESSAGING AFTERCARE SERVICE
Online Messaging is a Messaging Service for sending messages or photos during and after normal clinic hours for general medical assistance.

1. This service is available 24-hours a day and available for the first 14-days after your surgery only.
2. The service is only for medical questions relating to your recovery and aftercare.
3. This service is not provided for arranging appointments, requesting medical notes/letters or new patient referrals. 
4. Any requests in Point-3 of this section (Online Messaging Aftercare Service) may not be attended to if requested by this service. Please contact Berkeley Square Medical on 02078877607 or by email at info@berkeleysquaremedical.com for all other queries.

9.0 – RE-ADMISSION POLICY (Revision Surgery)
For up to 12 months after your procedure If, after your operation (allowing 12 months for recovery to be completed and for you to be assessed by your surgeon), you and your surgeon agree that revision surgery (as part of the original procedure) is necessary to correct a consented risk associated with your surgery, Berkeley Square Medical will offer a revision surgery at no additional Surgeon or Clinical cost. This does not include hospital, anaesthetic, and pre-operative test fees.

1. After 16-months from your surgery date, Berkeley Square Medical’s usual full fees will apply.
2. Berkeley Square Medical will not provide continuing surgery at special rates where the results of the surgery originally provided has been affected by changes in the lifestyle, illness or the natural ageing process.
3. Or where the original surgeon is not available Berkeley Square Medical reserve the right to review the basis upon which any additional surgery is provided.
4. This policy may be affected if the patient moves away from the area in which they lived when the original surgery was provided.
5. This policy may be affected if a patient fails to attend review appointments or follow advice and guidance as indicated by our clinical team.

10.0 – USE OF AI IN MEDICAL RECORD KEEPING

We may use artificial intelligence (AI) tools, including recording and dictation software, during both in-person and video consultations. These tools assist in capturing your medical history and treatment details before and after your procedure.

1. Purpose: AI technology is used solely to support accurate record-keeping as part of your clinical documentation.
2. Scope: This may involve transcription of your consultation and treatment notes using secure AI-enabled systems.
3. Review Process: All AI-generated documentation is manually reviewed and verified by qualified staff for accuracy and clinical appropriateness.
4. Confidentiality: Your privacy remains a top priority. All data is handled in accordance with GDPR and relevant UK healthcare data protection regulations.
5. By attending a consultation or treatment with us, you acknowledge and consent to this process as part of your medical documentation.

11.0 – ACCESS TO MEDICAL RECORDS
Patients may request to obtain a copy of their medical records. To obtain a copy a subject access request form must be requested from the clinic and completed.

1. Medical Leave Letters: £25.00
2. Surgeon Notes: £0.00
3. Surgery and Theatre Notes: £0.00

Optional Consent – Use of Photographs for Media and Educational Purposes
Photos are taken pre-operatively and at post operative stages of your surgery journey. These are contained within your medical history at Berkeley Square Medical.  I consent to Berkeley Square Medical using my medical photographs (e.g., before and after images) for educational, informational, and marketing purposes, including but not limited to social media, websites, and printed material.
I understand that my identity will be protected unless I have agreed otherwise, and that this consent is completely voluntary and has no impact on my care or treatment.

1. A written complaint acknowledged within 7 working days
2. A formal response made within 28 working days

 13.0 – DATA PROTECTION

1. BSqM processes data relating to patients in connection with the Relevant Treatment provided to those patients in accordance with these terms and conditions.
2. BSqM wishes to disclose data relating to Patients to the Surgeons, Doctors and Nurses during the Relevant Treatment and BSqM wish to have the consent of the Patient to such disclosure.
3. The patient is deemed to consent to the disclosure of sensitive personal data by BSqM to Surgeons, Doctors and Nurses for the purpose of discussing the Patients Treatment.
4. The Patient acknowledges that BSqM is obtaining this consent for themselves in order that they may comply with the provisions of the Data Protection Act 1998.

 14.0 – LEGAL JURISDICTION

1. The service provided by BSqM, and the Relevant Practitioners shall be governed by the laws of England and Wales, whose courts shall have exclusive jurisdiction.

15.0 – FORCE MAJEURE CLAUSE

This section is in the unlikely event that a medical appointment, treatment, or surgery has to be rescheduled due to a force majeure event.

Examples of Force Majeure incidents include but are not limited to natural causes (fire, storms, floods), governmental or societal actions (war, invasion, civil unrest, labour strikes), infrastructure failures (transportation, energy), medical professionals involved in your treatment who are unfit/unwell to conduct your appointment or surgery.

15.0.1 – What you are fully covered for:

1. Any rescheduled fees associated with your appointment, treatment or surgery.
2. Undertaking a new MRSA test (if applicable).

15.0.2 – What you are not covered for:

1. Travel or accommodation costs associated with attending your appointment, treatment or surgery.
2. Any pre-operative tests conducted less than 72-hours before a treatment or surgery. E.g A COVID-19 Lateral Flow Test.

15.1

1. In the event of a force majeure incident, the Reschedule Policy (Section: 4.0) will not apply.
2. In the event of a force majeure incident, the Cancellation Policy (Section: 5.0) will be applied should you decide to cancel your appointment, treatment or surgery.

• Our GDPR Privacy policy is also available to all patients at: PRIVACY POLICY – CLICK HERE