CONSENT: Your consent and authorization for this procedure is strictly voluntary. By signing this informed consent form, you hereby grant authority to you provider to perform insertion of PDO Suture Threads for lifting and rejuvenation purposes and/or to administer any related treatment as may be deemed necessary or advisable in the diagnosis and treatment of your condition.
The nature and purpose of this procedure and the potential complications and side effects have been fully explained to me. Alternative treatments and their risks and benefits have been explained to me as well and I understand that I have a right to refuse treatment. I agree to adhere to all safety precautions and instructions after the treatment. I have been instructed in and understand post treatment instructions and have been given a copy of them. I understand that NO REFUNDS will be given for treatments received. No guarantee has been given by anyone as to the results that may be obtained by this treatment.
I have read this informed consent and certify that I understand its contents in full. All of my questions have been answered to my satisfation and I consent to the terms of this agreement. I have had enough time to consider the information given to me by my provider and feel that I am sufficiently advised to consent to this procedure. I accept the risks and complications of the procedure. I certify if any changes occure in my medical history I will notify the office.
I hereby give my voluntary consent to this procedure and release my provider, the facility, staff, and designated technicians from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age and am not under the influence of alcohol or drugs. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representitives, heirs, administrators, successors and assigns.
Should I have any questions or concerns regarding my treatment/results, I will notify this office at 215-422-3690 immediately so that timely follow-up and interventions can be provided.