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:

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.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.

Signature

(Patient Signature)

Signature

(Healthcare Provider Signature)

Date

PDO THREADS PATIENT CONSENT FORM