Dermal Filler
The purpose of this informed consent form is to provide a written copy of the information your doctor or medical technician discussed with you regarding the risks, benefits and alternatives of the treatment named above, and to document your consent to this treatment. This document serves as a supplement to the discussion you have with your doctor or medical technician. It is important that you fully understand this information, so please read this document thoroughly.
Please initial every paragraph of this form that has the words "Initial " to confirm that you
have read and understood that paragraph. If you do not understand or accept any paragraph, please advise your doctor or medical technician and do not place your initials on this form. If you have any questions regarding the treatment, ask your doctor or medical technician prior to signing the consent form. You may withdraw consent at any time by telling the doctor or medical technician performing the treatment.
THE TREATMENT
Platelet-Rich Plasma (PRP) Scalp Treatment is used to treat hair loss by triggering a healing response in the skin of the scalp and hair follicles. PRP is defined as a volume of autologous (your own) plasma that has a platelet concentration above that found in whole blood. As such, PRP contains not only a high concentration of platelets but also the full content of plasma clotting factors. PRP is created by drawing a small sample of your blood which is spun in a centrifuge to separate the PRP, removing red and white blood cells, which delay the healing and concentrating platelets, thereby increasing factors used in healing. The PRP is then applied to the treatment area using either a Mesotherapy Gun and needle and syringe or the Dermapen micro-needling device. Both of these devices administer the PRP deep into the skin using different methods described in more detail below. All steps must occur in the same procedure and PRP cannot be stored for future use. Treatments take approximately 45 minutes to an hour and multiple treatments are advised to obtain the full effects. There is minimal downtime and normal activities can generally be resumed within 24 hours of treatment. This treatment may be performed by a doctor or a medical technician
You are aware that this treatment involves drawing your blood and administering a by-product of your blood, PRP, to the skin of the neck and decolletage using either injection or micro-needling techniques.
You are aware that to achieve the best results several sessions may be required
You have discussed the number of treatments you will receive with your doctor or medical technician. You are aware that your treatment may be performed by either a doctor or a medical technician.
If using the Mesotherapy Gun and needle and syringe, the treatment will consist of many injections of small amounts of PRP under the skin. As with any injection, you may experience some discomfort during the treatment but most patients find treatment tolerable. Your doctor or medical technician may apply a numbing cream to reduce discomfort during treatment
If using the Dermapen micro-needling device, treatment will consist of making several small punctures in the surface of the skin while applying PRP. Microneedling is not an injection but does involve piercing the skin with needles. You may experience some discomfort during the treatment but most patients find treatment tolerable. Your doctor or medical technician may apply a numbing cream to reduce discomfort during treatment.
You are aware of the differences between mesotherapy and micro-needling and have discussed which method will be used to administer the PRP with your doctor or medical technician. You are aware that a numbing cream may be applied to reduce discomfort during treatment
A minimum of one month is required in between treatments. It is also recommended that treatment be undertaken 3-4 weeks prior to any special event or vacation. This treatment may not be suitable for those who have had planned or past cosmetic treatments in the treatment area. This treatment is safe to use in combination with laser treatments. This treatment may not be suitable for those who are using antibiotics, corticosteroids, anticoagulants, or antiplatelet medication (including aspirin and ibuprofen)
You are aware that this treatment should be undertaken 3-4 weeks prior to any special event or vacation.
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You have notified the doctor or medical technician of any other planned or past cosmetic treatments in the treatment area, including PRP treatments. You have notified the doctor or medical technician if you are taking any antibiotics, corticosteroids, anticoagulants, or antiplatelet medication
RESULTS
The effects of treatment are generally visible in 1-4 weeks and continue to develop gradually for the following 3-6 months. Results may last 18-24 months and additional treatments are required to maintain benefits. PRP is approved by Health Canada for autologous cosmetic use only. Like any cosmetic treatment, there is no guarantee that you will be completely satisfied. There is no guarantee that treatment will resolve the issues you wish to target. initial
The effects of this treatment are dependent on many factors, including but not limited to: age, tissue conditions, sun exposure, and drug, alcohol or tobacco use. Following post-treatment care, instructions provided by your doctor or medical technician is recommended to maximize your results.
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You are aware that the effects of treatment may vary based on the above-listed factors and that ongoing treatments will be required to maintain results. You have been instructed in and understand the posttreatment instructions.
You are aware that follow-up treatments will be needed to maintain or enhance the effects of this treatment. You are aware that the effects of treatment, depending on the above-listed factors, may last up to 6 months and in some cases shorter and some cases longer. You have been instructed in and understand the post-treatment instructions.
RISKS AND COMPLICATIONS
Before undergoing this treatment, understanding the risks is essential_ No treatment is completely risk-free. Below is a list of the known risks of this treatment but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may require hospitalization or extended outpatient therapy to treat.
There are certain inherent and potential risks and side effects in any treatment that involve phlebotomy (drawing blood), injections, micro-needling, or the administration of PRP and in this specific instance such risks include but are not limited to:
1) Allergic reaction;
2) Nerve injury;
3) Dizziness or fainting;
4) Temporary blood sugar increase;
5) Excessive bleeding;
6) Post-treatment discomfort, swelling, burning sensation, redness, discoloration, and bruising in the treatment area;
7) Post-treatment infection associated with phlebotomy or transcutaneous injection;
8) Skin tightness lasting more than 36 hours after treatment;
9) Edema (abnormal gathering of fluid under the skin)
You are aware that this treatment has a risk of side effects, some of which may be unforeseen and are not listed above. You are aware that some side effects may be serious and require hospitalization or extended medical treatment. You understand that by choosing to undergo this treatment, you are accepting these risks.
PREGNANCY, ILLNESS AND ALLERGIES
TThis treatment should not be performed on women who are pregnant, intend to become pregnant or are nursing. This treatment has a low likelihood of triggering an allergic response because PRP is derived from your own blood, however, there are a number of other substances that you may come in contact with during the procedure, including latex, iodine, alcohol, novocaine or lidocaine. This treatment should not be performed on a patient presenting with
skin lesions or active viral or bacterial infections in the treatment area. This treatment may not be suitable for patients who have or have had major illnesses such as cancer in the treatment area, blood cancers, blood diseases,
auto-immune diseases, liver diseases or skin diseases. This treatment is not recommended for patients taking anticoagulants, undergoing chemotherapy, taking any medication that could alter platelet function, or using corticosteroids within the last two weeks. All major illnesses or allergies should be disclosed to the doctor or medical technician prior to signing this consent form.
You are not pregnant, do not intend to become pregnant and are not nursing. You have disclosed any medication you are taking to the doctor or medical technician performing this treatment. You have disclosed any major illnesses or allergies to the doctor or medical technician performing this treatment.
ALTERNATIVE TREATMENTS
There are alternative cosmetic, medical and surgical treatments that may be used to treat hair loss. If you wish to
discuss alternative treatments please ask the doctor or medical technician prior to signing this consent form.
You have discussed alternative treatments with the doctor or medical technician performing this treatment and have had an opportunity to ask any questions you may have about these alternatives
PAYMENT
This treatment is an elective cosmetic treatment not covered by the Ontario Health Insurance Plan ("OHIP"). Payment is expected at the time of treatment and you will be provided with an invoice or receipt for your records. The cost of treatment should be discussed with your doctor or medical technician prior to signing this consent form. Initial
You are aware that this treatment is not covered by OHIP and that payment is expected at the time of treatment. You are aware of and agree to pay the cost of treatment.
PHOTOGRAPHY
For the purpose of adequate record keeping, your doctor or medical technician will take close-up photographs of the treatment area(s) before, during, and after treatment. These photos are taken for the sole purpose of supporting
your care and treatment. These photos will form part of your medical record will be treated with the same confidentiality as other medical records.
You are aware that photos of the treatment area will be taken before, during, and after your treatment.
You are aware that these photos will be maintained in your medical record.
RIGHT TO DISCONTINUE TREATMENT
You have the right to discontinue treatment at any time by telling the doctor or medical technician performing the treatment If you have questions or concerns during the treatment, please inform the doctor or medical technician performing the treatment.
You are aware that you have the right to discontinue treatment at any time.
CONFIRMATION OF UNDERSTANDING
It is important that you understand this consent form and all of the information provided to you.
You are able to read and write in English and have read the above consent form and understand it. You have been told that you have the right to ask questions about the treatment and about this consent form. All of your questions have been answered to your satisfaction.
STATEMENT OF CONSENT
By signing this form, you confirm that you are aware that this is an elective cosmetic treatment and hereby voluntarily consent to treatment with dermal fillers for facial rejuvenation, lip enhancement, and/or replacing facial volume. The treatment has been fully explained to you including risks and potential side effects. You have had the opportunity to ask any questions you may have and those questions have been answered to your satisfaction. You accept the risks and complications of the treatment and you understand that no guarantees are implied as to the outcome of the treatment. If you have any post-treatment questions or concerns, or changes in your medical history, you will notify the doctor or medical technician who treated you immediately.
