A. CONSENT FOR PRIAPUS SHOT®/P SHOT® PROCEDURE

I have received information about my condition, the proposed treatment, alternatives, and related risks. This form contains a brief summary of this information. I have received an explanation of any unfamiliar terms and have been offered the opportunity to ask questions. Ihave not received any promise, guarantee or warranty that my undergoing the Priapus Shot®/P Shot® procedure will achieve a particular result.

I fully understand that individual results do vary, and that Erika Dominick CRNP assumes no responsibility for failure to achieve a desired result. I understand I may refuse consent and I GIVE MY INFORMED AND VOLUNTARY CONSENT to the proposed procedures and the other matters shown below. I also consent to the performance of any additional procedures determined in the course of a procedure to be in my best interests and where delay might impair my health.

1. I authorize Erika Dominick CRNP to treat my condition, including performing further diagnosis and the procedures described below, and taking any needed photographs.
2. I understand the proposed Priapus Shot®/P Shot® procedure(s) to be: a procedure for rejuvenating, enlarging and strengthening the penis, using blood-derived growth factors (plateletrich fibrin matrix (PRFM), platelet-rich plasma (PRP) injections.
3. I understand the risks associated with the proposed procedure(s) to be: possible 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, 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.
4. I also understand that there may be other RISKS OR COMPLICATIONS, OR SERIOUS INJURY from both known and unknown causes. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me concerning the risks of the procedure.
5. I understand that the use of PRP 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 and this procedure is approved by the FDA or any other agency of the federal or state government is made. I understand the alternatives to the proposed procedures and the related risks to be: do nothing.
   
   

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.

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.

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