• Consent for O-Shot® and Administration of Local Anesthesia

  • A. CONSENT FOR PROCEDURE [O-Shot(R)]
    The O-shot procedure consists of taking PRP and injecting between the urethra and the vagina, parallel to the internal location of the Skene’s glands. The optimal outcome would be to increase sexual arousal, help control urinary incontinence, and help dryness. 

    1. I authorize Erika Dominick, CRNP to treat my condition(s), including performing further diagnosis and the procedure(s) described below.
    2. I understand the proposed procedure(s) to be: vaginal submucosal/sub urethral, clitoral, and labial, PRP (platelet rich plasma) injection [The Orgasm Shot(R)/The O-Shot(R)].
    3. I understand the risk(s) associated with the proposed procedure(s) to be: Bleeding, infection, urinary retention, allergic reaction, abnormal sexual sensation continuing without stimulation, vaginal discharge, sexual function alternation, hematoma, urethral injury, urinary retention, hematuria (blood in urine), urinary tract infection (UTI), urinary urgency/frequency, increased/worsened nocturia, change in urinary stream, urethral/vaginal fistula, painful intercourse, need for subsequent procedures, alternation of vaginal sensation, scar formation, urethral stricture, local tissue infarction/necrosis, yeast infection, spotting between menses, bladder pain, overactive bladder, bladder fullness, pelvic pain/heaviness, erosions, fatigue, post-procedural pain, failed procedure, varied results, decreased sexual function, possible hospitalization d/t complications, lidocaine toxicity, anesthesia reaction, embolism, depression, anaphylactic reaction to lidocaine or calcium chloride, nerve damage, slow healing, swelling.
    4. I also understand that there may be other risk(s) and or complication(s), and or serious injuries from both known and unknown cause(s). I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantee(s) have been made to me concerning the risk(s) of the procedure. 
    5. I understand that the use of PRP in this procedure is an ‘off label’ use, no promise(s) and or representation(s), guarantee(s) and or warranty regarding its use, benefit(s), and or other qualities were made. I have been informed by the provider of other alternative(s) and I understand the alternatives as they were explained to me  
    6. No representation(s) that the use of the product(s) and the procedure(s) are approved by the FDA and or any other agencies of the federal and or state government were made.  
    7. No video(s), picture(s), and or recording(s) in the office and or during the procedure(s)   

  • B. CONSENT FOR ANESTHESIA
    When local anesthesia and or sedation is used by the provider: I consent to the administration of such local anesthetics as may be considered necessary by the provider in charge of my care. I understand the risk(s) of local anesthesia include but are not limited to: local discomfort, swelling, bruising, allergic reactions to medications, and seizures from lidocaine.

    C. PATIENT CERTIFICATION:
    I have received information about my condition, the proposed treatment, alternative(s), and related risk(s). This form contains a summary of this information. I have received an explanation of any unfamiliar terms and have been offered the opportunity to ask questions. I understand I may refuse consent at any time. I have read and understand this form, and I give my informed and voluntary consent to the proposed procedure(s). I also consent to the performance of any additional procedure(s) determined by my provider during the procedure(s). By signing below, I state that I am 18 years of age or older, or otherwise authorized to consent.

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  • D. PROVIDER ATTESTATION
    I have explained the procedure(s), alternative(s) and risk(s) to the person or persons whose signature is affixed above. The patient has verbally communicated to me that they understand the consents of this form.

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  • E. INTERPRETER ATTESTATION (when applicable)
    I have provided translation to the person(s) whose signature(s) is affixed above.

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