CONSENT FOR TREATMENT

PDO Thread Treatment

Treatment with hyaluronic acid and other injectable dermal fillers can help smooth out folds and wrinkles, add volume to the cheeks, temple, lips, and contour facial features that have lost their fullness due to aging, sun exposure, illness, etc. In healthy individuals without autoimmune issues or infections, HA fillers and other injectable dermal fillers can be performed with minimal to no complications in most cases, however, I have reviewed risks and consent to treatment.

Risks and Complications include but are not limited to the following. Please check each box indicating acknowledgement:


  • Facial Bruising, redness, swelling, itching and pain. These symptoms are usually mild and last less than a week but can last longer. Patients who are using medications that can prolong bleeding, such as aspirin, Warfarin, or certain vitamins and supplements, may experience increased bruising or bleeding at the injection site.
  • Nodules and palpable material. You may be able to feel the filler material in the area where the material has been injected. Any foreign material injected into the body may create the possibility of swelling or other local reactions to a filler material.
  • Migration. Filler may move from the place where it was injected.
  • Infection. All transcutaneous procedures carry the risk of infection.
  • History of Herpes Infection. Filler carries the risk of a recurrence of an outbreak of herpes and that outbreak could be severe in nature.
  • Allergic Reactions.
  • Keloids/Scarring. Known susceptibility to keloid formation or hypertrophic scarring has not been studied.
  • Accidental Injection into a blood vessel. Filler can accidentally be injected into a blood vessel, which may block the blood vessel and cause local tissue damage or potentially even a heart attack, stroke, or blindness.
  • Duration of Effect. The outcome of treatment will vary among patients. In some instances, additional treatments may be necessary to achieve desired outcomes.
  • Concomitant Dermal Therapies. I understand that the safety of dermal fillers with concomitant dermal therapies such as epilation, UV radiation, laser, mechanical or chemical peeling procedures, massage, use of clarisonic skin cleansing brush has not been evaluated in controlled clinical trials. The use of any of these procedures is not recommended as such treatments may alter the characteristics of the filler for 2 weeks following this treatment.
  • It is not recommended that you have dermal fillers injected if you are nursing or pregnant.
  • Sun Exposure. Sun exposure should be minimized for approximately 24 hours after treatment or until any initial swelling or redness goes away.
  • There are very rare times where people can develop delayed swelling or a delayed inflammatory nodule that seems to be triggered by some sort of immune system stimulation like an infection somewhere in the body or even after a vaccination.
  • authorize the taking of clinical photographs for purposes of documentation of treatment. I understand that refusal of photos will result in not having treatments performed.


Please check each box as acknowledgement of each statement:

  • I am not pregnant or trying to become pregnant nor am I breastfeeding
  • I do not have any major illnesses, including Auto-immune issues or active cancer
  • I do not have multiple allergies or high sensitivity to medications, including but not limited to lidocaine or bee stings.
  • I am in an optimal state of health and have not been ill for the past 4 weeks.
  • I have not received any recent vaccines in the past two weeks.
  • I am not traveling outside of the country in the next 7 days.
  • I have not recently, nor am I planning any dental procedures in the next 4 weeks.
  • I am being honest and truthful about my medical history including sharing any past facial surgeries and previous injections.

Cost/Fees Payment for this cosmetic procedure is my responsibility. I understand that there will be an additional fee for touch ups. I understand that this is an "elective" procedure and I am undergoing treatment of my own free will. Payment is my full responsibility regardless of outcome and is due at the time of my treatment. I understand that there are no refunds for such elective treatments. I accept responsibility for any complications that may occur and thereby absolve Medfit of Georgia or any associated person of any blame resulting there from. In agreeing to such, I also agree to no credit card chargebacks given the elective nature of my treatments. I understand that there is no guarantee of any particular results of any treatment. I also understand that follow-up treatments with additional fillers may be necessary to achieve full correction and this is at an additional fee. I am aware that the duration of treatment is dependent on many factors. I will report any concerns including abnormal swelling, pain, color changes, or lumps to my provider.


I hereby voluntarily consent to treatment. The procedure(s) has been explained to me. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure. I certify that if I have any changes occur in my medical history, I will notify the office. By signing below, I acknowledge that I have read the foregoing informed consent, have had the opportunity to discuss any questions that I have with my provider to my satisfaction, and consent to the treatment described above with its associated risks. I hereby release the Medfit of Georgia and any associate there of from liability associated with this procedure. This consent form is valid until all or part is revoked by me in writing. This consent is valid for all future filler injections in the future as well.

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INSTRUCTIONS: This is an informed consent document that has been prepared to help apprise you of the PDO Lift Procedure, its risks, possible complications, and alternative treatments. It is important that you read this information carefully and completely. Please initial each section, indicating that you have read the page and sign the consent for the procedure proposed by your practitioner.

INTRODUCTION: PDO Lift uses absorbable polydioxanone surgical sutures placed into the subdermal layer of the skin to stimulate collagen production. This can result in increased firmness and elasticity of the skin in the treated area. PDO Lift is effective in most cases; however, no guarantees can be made that a specific patient will benefit from this procedure. Additionally, the nature of cosmetic procedures may require a patient to return for numerous visits in order to achieve the desired results or to determine whether or not to be completely effective at treating the particular condition. Therefore, this permission for care will be effective for (1) year from the date of execution with respect to the above outlined procedure(s).

ALTERNATIVE TREATMENTS: Alternative forms of non-surgical and surgical management consist of surgical facelift, Nd:YAG Laser, full-face C02 Laser, dermal fillers, local muscle relaxer (Botox) chemical peels, or doing nothing at all. Every procedure involves a certain amount of risk, and it is important that you understand the risks involved. An individual's choice to undergo a procedure is based on the comparison of the risk to the potential benefit. Although the majority of patients do not experience these complications, you should discuss each of them with your practitioner to make sure you understand the risks, potential complications, and consequences.

POSSIBLE RISKS and SIDE EFFECTS ASSOCIATED with a PDO Thread Treatment:

1. DISCOMFORT: Some discomfort may be experienced during treatment.
2. SCARRING: May cause scarring. Sutures are inserted via a small acupuncture type needle, which must heal. A scar at the entry point(s) may occur.
3. BRUISING, SWELLING, INFECTION: With any minimally invasive procedure, bruising of the treated area may occur. Additionally, there may be swelling. Finally, skin infection is rare, but a possibility with any injection or incision into the skin.
4. BLEEDING: It is possible to experience some bleeding during or after the procedure. Hematoma or small blood clot may occur and may require treatment by drainage. There is a higher risk of bleeding if you have taken any anti-inflammatory medications (Aspirin, Advil, Motrin, ibuprofen) for ten (10) days before surgery.
5. DAMAGE TO DEEPER STRUCTURES: Deeper structures such as nerves, blood vessels and muscles may be damaged during the course of procedure. The potential for this to occur varies according to the location on the body the procedure is being performed. Injury to deeper structures may be temporary or permanent.
6. ALLERGIC REACTIONS: Allergies to tape, suture material, or topical preparations have been reported. Allergic reactions may require additional treatment.
7.ANESTHESIA: Local topical anesthesia may be used and can involve risk of allergic reaction and rash.
8. PIGMENT CHANGES (SKIN COLOR) (hyper or hypo-pigmentation): There is a possibility of the treatment area either becoming lighter or darker in color than the surrounding skin. This is usually temporary, but on rare occasions, may be permanent. Appropriate sun protection is very important.
9. PARTIAL LAXITY CORRECTION: PDO Lift may not correct all your facial laxity.
10. DELAY HEALING: Complications may ensue as a result of smoking, drinking liquids through a straw, or similar motions. Because of this, smoking and similar actions are STRONGLY discouraged.
11. CONTRAINDICATIONS: Any known allergy or foreign body sensitivities to plastic biomaterials.
12. OTHER: Slight asymmetry, redness, visible suture(s) may require additional treatment and or the removal of the sutures.

ADDITIONAL PROCEDURES MAY BE NECESSARY

In some situations, it may not be possible to achieve optimal results with a single PDO Lift procedure and other procedures may be necessary. The practice of medicine is not an exact science. Although good results are expected, there cannot be any guarantee or warranty expressed or implied on the results that may be obtained.

The cost of the procedure may involve several charges for the services provided. The total may include fees charged by our medical staff, the cost of supplies, or laboratory tests if needed. Additional costs may occur should complications develop from the procedure.

I understand that no warranty or guarantee has been made to me as to the result or cure. I realize that, as in all medical treatment, complications or delay in recovery may occur which could lead to the need for additional treatment, and could also result in economic loss to me because of my inability to return to activity as soon as anticipated.

I understand that my practitioner may discover other or different conditions, which require additional or different procedures than those planned. I authorize the practitioner and such associates, technical assistants and other health care providers to perform such other procedures which are advisable in their professional judgment.

I understand that my cheeks or jowls may not achieve the desired improvement in shape that was anticipated.

I understand that sutures may extrude, and may have to be trimmed or removed in the future.

I understand that the results may relax over time and additional procedures may be required.

CONSENT

Your consent and authorization for this elective procedure is strictly voluntary. By signing this informed consent form, you hereby grant authorization to our medical staff to perform PDO Lift and/or to administer any related treatment as may be deemed necessary or advisable in the diagnosis and treatment of your condition.

The nature and purpose of this elective procedure and the complications and side effects have been fully explained to me. Alternative treatments and their risks and benefits have been explained to me and I understand that I have a right to refuse treatment. I agree to adhere to all safety precautions and instructions after the treatment. I have been instructed in and understand post treatment instructions and have been given a written copy of them. I understand that no refunds will be given for treatments received. No guarantee has been given by anyone as to the results that may be obtained by this treatment.

I have read this informed consent and certify that I understand its contents in full. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I have had enough time to consider the information given to me and feel that I am sufficiently advised to consent to this procedure. I accept the risks and complications of the procedure. I certify if any changes occur in my medical history I will notify the office.

I hereby give my voluntary consent to this elective procedure and release the facility, medical staff, and specific technicians from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age and am not under the influence of alcohol or drugs. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.

I agree, if I should have any questions or concerns regarding my treatment / results I will notify this office immediately so that timely follow-up and intervention can be provided.

Patient Information

Patient's Name
Clear Signature
Date of Consent
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