PDO Threads Patient Consent Form

I, First Name Patient* Last Name Patient* hereby authorise First Name Doctor Last Name Doctor ; to perform the placement of PDO threads (absorbable synthetic thread sutures) and the injection of local anesthetic for the purposes of treating skin laxity and/or general facial rejuvenation.

I FULLY UNDERSTAND AND ACKNOWLEDGE THAT:*

I am freely choosing to under go these medical procedures and accept all the inherent risks associated with them.Treatment, such as that to which I have consented to receive, are medical procedures that carry with them certain potential complications and side effects, both local and systemic. I understand that these treatments may result in undesirable outcomes for which further treatment may be necessary and this would be at my own cost. I undertake treatment solely at my own risk and indemnify my Doctor against the occurrence of such potential complications.I have received detailed information, in clear terms, regarding the alternative treatments available; contraindications; potential complications and side effects of treatment.I have been given the opportunity to ask questions about the proposed treatment and I now fully understand and accept the benefits, risks, complications and side effects, both immediate and long-term, general and specific, which these procedures may cause.Potential complications and side effects may include, but are not limited to, permanent or temporary, general or specific - pain, tightness, pulling, swelling, redness, burning, stinging, tenderness, bleeding, bruising, headache, nausea, muscle damage, paraesthesia, nerve damage, skin infection, skin granuloma/necrosis/death, scarring, serious allergic reaction (anaphylaxis), facial asymmetries, aesthetic and functional defects such as skin distortions and puckering, as well as damage to other vital structures.Should complications occur as a result of treatment I receive, I may require emergency, life-saving or corrective treatment and that I am solely responsible for any costs associated with such required treatment.When completing the medical history, I have done so to be best of my knowledge and have not willingly withheld any information. I understand that treatment is temporary in nature and will require re-treatment after a period of time, the length of which depends on various personal circumstances and the area being treated.I am solely responsible for reporting post-operative complications, following post-operative instructions and attending my scheduled review appointment. I understand that failure to do so may affect the results of treatment and be hazardous to my health.I have been informed that medical treatment is not an exact science and that no guarantees can or have been made with respect to the anticipated results and that further treatment will likely be required to achieve the desired outcome for which I must pay a fee.

Signature*

(Patient Signature)

Signature*

(Healthcare Provider Signature)

Date*

PDO THREADS PATIENT CONSENT FORM