I the patient first name, last name have been explicitly and thoroughly informed by Dr Kaushik that smoking is a great risk for vascular development and vascular healing and poses a great overall risk for healing after surgery in general, due to the toxic cigarette elements, that enter the body.
I, therefore, commit to non-smoking for at least 2 months prior to surgery and to at least 1 month of non-smoking past surgery.
Failure to do so poses a great overall risk and the risk of healing issues. Also graft taking issues can arise out of neglecting this order from Dr Kaushik.
Should I the patient first name, last name disobey these orders, I will do so on my own risk, knowing that I might jeopardise all or some of the results of the surgery I am to undertake.
Location and Date : _____________________
Patient Signature : _____________________
Dr. Kauhsik Signature : ______________________