THE TREATMENT

Priapus Toxin™ procedure - Botulinum Toxin A is a neurotoxin produced by the bacterium Clostridium A. After preparation, Botulinum Toxin A is injected into the corpus cavernosi of the penis to improve penis tissue health and enhance erectile function or penis size.

I authorize Dr. Patrick Yam and/or his delegated medical staff to treat my condition, including performing further diagnosis and the procedures described below, and taking any needed photographs.

I understand the proposed Priapus Toxin™ procedure to be: a procedure wherein Botulinum Toxin A is injected into the corpus cavernosi of the penis to improve penis tissue health and enhance erectile function or penis size.

I understand that the use of Botulinum Toxin A in this procedure is an “off-label” use, and no promise or representation, guarantee or warranty regarding its use, benefit or other quality is made. No representations that the use of this product for this procedure is approved by the FDA or any other agency of the federal or state government is made. Alternatives and options to the procedure have been fully explained to me.

Risks of the Treatment

Before undergoing this procedure, understanding the risks is essential. No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list.  Some of these risks, if they occur, may necessitate hospitalization and/or extended outpatient therapy to permit adequate treatment. It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure and in this specific instance such risks include but are not limited to:

Bleeding; Infections; Urinary retention; No effect at all; Allergic reactions; Mental preoccupation of the penis; Alteration of the function of the penis; Sexual function alteration; Hematoma ;Increased/worsening nocturia (waking up several times at night to urinate); Change in urinary stream; Need for subsequent surgery; Alteration of penile sensations; Scar formation (penile); Local tissue infarction and necrosis; Fatigue; Alteration of bladder dynamics; Post-operative pain; Prolonged pain; Intractable pain; Alteration of the male sexual response cycle; Failed procedure; Varied results; Psychological alterations; Relationship problems; Sex life alteration; Decreased sexual function; Possible hospitalization for treatment of complications; Lidocaine toxicity; Anesthesia reaction; Embolism; Depression; Reactions to medications including anaphylaxis; Nerve damage; Permanent numbness; Slow healing; Swelling; Sexual dysfunction; Allergy; Nodule formation; Post treatment discomfort, swelling, redness, and bruising; Post treatment bacterial, and/or fungal infection requiring further treatment; Allergic reaction: hives, itching; wheezing, difficult breathing; feeling like you might pass out; swelling of your face, lips, tongue, or throat;Transient headache;Flu-like symptoms, fever, chills, body aches; unusual or severe muscle weakness (especially in a body area that was not injected with the medication); loss of bladder control; hoarse voice, trouble talking or swallowing; drooping eyelids or eyebrows; vision changes, eye pain, severely dry or irritated eyes (your eyes may also be more sensitive to light); chest pain or pressure, pain spreading to your jaw or shoulder, irregular heartbeats; pain or burning when you urinate, trouble emptying your bladder; sore throat, cough, chest tightness, shortness of breath; eyelid swelling, crusting or drainage from your eyes, problems with vision; painful or difficult urination; headache, neck pain, back pain, pain in your arms or legs; cold symptoms such as stuffy nose, sneezing, sore throat; increased sweating in areas other than the underarms; and bruising, bleeding, pain, redness, or swelling where the injection was given. 

RIGHT TO DISCONTINUE TREATMENT

I understand that I have the right to discontinue treatment at any time. 

PAYMENT

I understand that this is an "elective” procedure, and that payment is my responsibility and is expected at the time of treatment.

PATIENT CERTIFICATION / ELECTIVE PROCEDURE

By signing below, I state that I am 18 years of age or older, or otherwise authorized to consent. I have read or have had explained to me the contents of this form. I understand the information on this form and give my consent to what is described above and to what has been explained to me. My questions have been answered satisfactorily. I accept the risks and complications of the procedure and I understand that no guarantees are implied as to the outcome of the procedure. I also certify that if I have any changes in my medical history, I will notify the doctor/healthcare professional who treated me immediately. I also state that I read and write in English.