Patient Consent Form

Risks: This authorization is given with the understanding that any operation or procedure involves some risks and hazards. The more common risks can include the following: infection, bleeding, pain, swelling of the forehead and eyes, bruising, numbness, temporary redness of the scalp, ingrown hairs and allergic reactions. Some significant and substantial risks in this operation include poor or less than desirable results, scarring, and the need for additional transplant sessions. There may be additional risks associated with Follicular Unit Extraction (FUE) and recipient site making in particular and may include ingrown hairs in the donor area, inflamed cysts requiring surgical removal, scars larger than 1mm in diameter, less hair growth than would be expected from grafts obtained by strip harvesting methods, and detectability of scars when the head is shaved.

Dugs and Anesthesia: rThe administration of drugs and anesthesia, even local, also involves risks, most importantly, a rare risk of reaction to medications causing death. I consent to the use of drugs and anesthesia as may be considered necessary by (Dr. Germain).

Additional Procedures: If my doctor discovers a different, unexpected condition at the time of the procedure, I authorize her to perform such treatment as he deems necessary.

Permission of Photo use: I give (Marguerite Germain, MD, Germain Dermatology) permission to use my photos on her website, photo book and/or be used for teaching purposes. I understand that my face will be blocked out and my name will not be used without my permission.

No Guarantee: I understand that no guarantee or assurance has been made as to results of the procedure and that it may not cure the condition.

Questions and Answers: I have read and fully understand this consent form, and understand that I should not sign this form if all items, including all my questions, have not been explained or answered to my satisfaction, or if I do not understand any of the terms or words contained in this consent form.

The undersigned hereby agrees for the benefit of Venus Concept Ltd. and its affiliates to the following:

THIS IS A LEGAL DOCUMENT. IT IS IMPORTANT AND ADVISABLE THAT YOU READ THIS INFORMATION CAREFULLY AND COMPLETELY.

Treatments:  All Hair Restoration Procedures are elective, and a claim will not be filed with your Insurance Company.

Consultations:  We offer complimentary consultations to help determine which hair restoration treatment may be most beneficial to help you to achieve your goals.

Deposit:  A Nonrefundable $3,000 deposit is required to schedule and reserve your Hair Restoration Procedure Date on the Surgical Calendar. We are reserving our Operating Room, Staff, and Team of Specialists for the entire day of your procedure and are excited to be such a big part of your investment in yourself! This requires a lot of planning, time, and resources for all involved.

Balance: The Remaining Balance must be paid in full 2 weeks prior to the Procedure Date, otherwise we will open the Date back up on the Surgical Calendar to other patients until the Balance is paid.

Rescheduling/Cancellations: Outside of 3 weeks of the Procedure Date, we allow a one-time, courtesy rescheduling which the non-refundable deposit may be applied to. Any changes or cancelations inside of 3 weeks of the Procedure Date will result in the forfeiture of the non-refundable deposit.

THE WEEKS PRIOR TO YOUR PROCEDURE

• If you are taking any blood thinners, please let the doctor know immediately. These medications include Plavix, Coumadin, Heparin, Xarelto, and Pradaxa.

• Do not take any vitamin B or E for one week before your procedure. This includes any multivitamins that contain these vitamins as these will increase bleeding. They can be resumed three days following surgery.

• Do not take Aspirin or aspirin-containing products (Advil, Bufferin, Excedrin, Motrin, Ibuprofen, etc.) for two weeks prior to the procedure. These can be resumed three days after surgery. You may take Tylenol.

Other prescription medications (including heart and blood pressure medication) should be taken as prescribed right up to and including the day of your procedure. If you do take Finasteride, omit intake until the following night after the procedure.

IF you have longer hair, it is a good idea to get a shorter haircut from your barber (NO SHORTER THAN 2 GUARD) on the back and sides of the scalp as we will have to buzz your hair day of the procedure to properly extract the donor follicles.

• Stop smoking one week prior to the procedure. You may resume two weeks after the procedure.

• Avoid alcohol, wine, or beer one week prior to the procedure.

• If you color your hair, it is recommended that you color your hair a few days before your procedure.

• If you are using Minoxidil (Rogaine), stop five days prior to procedure, and resume two weeks after procedure.

THE DAY OF YOUR PROCEDURE

On the day of your procedure, arrival will be at 7:00 am. Please call (843) 773- 5803 once arriving.

• Shower the morning of your procedure and wash your hair very thoroughly using your regular shampoo. Do not apply any spray, gels or styling products to your hair.

• Wear loose, comfortable clothing including an old button-up shirt. This will prevent dislodging your bandage or damaging your grafts after surgery.

• Eat a hearty breakfast the morning of your procedure. Bring light snacks and drinks to nourish yourself throughout the day. (We will always keep things on hand, but just in case you have dietary restrictions, you should bring your own supply.)

• Do not drink coffee or any other caffeinated beverages the morning of your procedure.

• Plan to have someone take you home following your procedure since you will be unable to drive; or an Uber is acceptable.

• Bring the medications that were called in to your pharmacy with you on the day of the procedure. We will administer the medications once you check in at the practice

• Bring headphones, a tablet, or music source, as there is down time during the procedure.

 

If you have any questions, please contact our office Monday through Friday from 8am to 5pm at 843-881-4440. If it is after hours or weekends, please call: Dr. Germain: 843-810-2969 or Sam Jeremy at 419-564-0039.

INSTRUCTIONS AFTER YOUR PROCEDURE

Please note: These instructions have been carefully prepared by your physician. If you have any questions after your procedure, the first thing to do is review this information. If you are having a medical emergency: Dr. Germain’s mobile phone (for emergency use only) is 843-810-2969. Before you call the doctor be certain to have the number of a local pharmacy that is open in the event she needs to prescribe medication.                                                                                                                                                                                          

GENERAL INSTRUCTIONS

• After your procedure, you should be driven home by a ride that you arranged prior to your procedure. Once home, minimize your activity and eat a good meal.
  
  
• As anesthesia wears off you may begin to experience itching, tingling, soreness and/or tightness throughout the scalp. This is normal and will slowly resolve over the course of 5-7 days.
  
  
• Take pain and sleeping medication as prescribed. If you were taking finasteride (Propecia) prior to procedure, you may resume it the night after procedure.
  
  
• DO NOT take any aspirin or aspirin-containing products or drink alcohol for 5 days following your procedure.
  
  
• DO NOT smoke for 2 weeks following your procedure.
  
  
• Please sleep upright in a recliner or on sofa with back pillows the first three nights with a neck pillow to reduce swelling and reduce chances of dislodging grafts in your sleep.

1.    Care of Scalp

• 24 hours after surgery, remove your bandage. Let the scalp air dry and scabs form for the next 2 days without washing your scalp. You may apply Cerave to the donor area (back of the scalp) and spray the transplanted area with saline to keep it hydrated.
  
  
• Starting Night 3, Wash your scalp with baby shampoo and water in a cup, do not let direct shower pressure hit your scalp for 10 days.
  
  
• You may wear a high-crowned, structured baseball cap with adjustable band on back starting day 4. Loosen up strap fully when putting hat on to avoid friction with transplanted area, bring down over transplanted area, and then tighten strap in back when sweatband is on forehead so that no material is physically touching the scalp where grafts were transplanted while wearing. When taking hat off, release back strap and then pull hat straight up, so that no material of hat touches transplanted area while removing. Feel free to bring a hat with you the day of the procedure and we can show you how to properly wear it.
  
  
• Using the same cup, fill with clean water, pour over transplanted area two to three times to remove shampoo. Pat dry
  
   
• Continue this for 10 days. Resume your normal shampoo regimen on the 11th day.
  
  
• Redness, swelling, and slight tenderness are to be expected for the first few days after the procedure. The swelling may extend to the forehead and occasionally even to the area of the eyes. Again, this is to be expected and is harmless. It will resolve over the next few days.
   
• Reminder: Do not dye your hair for four weeks following the procedure. Do not use cosmetic camouflage agents (such as Toppik) for at least seven days following your procedure. After the procedure, you must wait 6-8 weeks before you can color hair again and a semi-permanent color should be used rather than permanent due to damage on your new grafts. Resuming to permanent dye can resolve at 3 months post op.
  
  
• It is important when shampooing, or rinsing the transplanted area, that you are gentle for the first 10 days following surgery. DO NOT RUB, PICK, OR SCRATCH TRANSPLANTED AREA, as this may dislodge grafts.
  
  
• Please avoid unprotected exposure to sunlight for three months (this includes tanning beds). Wear a hat when you are going to be outside. After two weeks, you may use a strong physical sunscreen with a SPF of 30+ or higher. We recommend using Germain Dermatology products to steer away from chemical components (may irritate the recipient area).

EXERCISE & WORK

• Refrain from heavy work/sweating/straining and weight lifting for 1 week.
  
  
• Some people return to light work the next day, although most prefer to take at least 2-3 days off. Because of the possibility of swelling and some crusting following the procedure, some people prefer to take 1 week off. Crusting will be more visible if you have little hair, to begin with. Crusts typically fall off 7-10 days after the procedure.

 

HAIR WASHING & HAIR CARE

• Hairspray and mousse may be used 2 weeks after the transplant but should be washed off daily.
  
  
• No combing of hair for 1 week following the procedure. When you start, do so carefully to avoid dislodging any grafts.
  
  
• During the first 3 days, a graft may be dislodged or combed out. Do not panic. It is uncommon and even if it happens, it is rare to lose more than a few hair follicles this way.
   
• Avoid hair dryers for 2 weeks.
   
• Hair coloring, perming, or cutting can be resumed at 4 weeks after your procedure.

 

SHOCK-LOSS

• Be aware that the short hairs in the transplanted follicles will fall out approximately ten days to two weeks following the procedure. Do not be concerned. This is a common occurrence.
  
  
• The transplanted follicle will go into a resting phase. In approximately three months, a new hair will be generated and begin to appear.

 

SWELLING

• If you should experience swelling, it usually occurs around the second to fifth-day post-op. It always resolves by itself after a few days and doesn’t require any special treatment. It should not be a cause for concern. As gravity works, the swelling may descend to the eyelids, and on rare occasions, blackening of the eyes may occur. This is uncommon, and though unsightly, will not leave permanent marks.
  
  
• Apply an ice pack to your forehead for up to 20 minutes per hour to help minimize any discomfort and swelling (DO NOT place directly on grafts).
  
  
• Massage your forehead after ice application. Start in center and push to the sides. This will help minimize potential swelling (DO NOT touch grafts).
  
  
• Swelling can be reduced by sleeping with your head elevated with additional pillows, or sleeping in a recliner at 45 degrees for the first 3 nights.

 

MEDICATIONS

• Many people require mediation for the first 48 hours after the procedure to minimize discomfort. Please only take Tylenol or Tylenol XL, no Advil or Ibuprofen.
  
  
• You will receive a prescription for pain control and anxiety. Use these as needed and directed. DO NOT drive or drink any alcohol while taking any of these pain medications. If you complete your prescription, you may use over-the-counter medications such as Tylenol. Take as directed.

FOLLOW-UP APPOINTMENT

 

Recommended follow-up dates