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.
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
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.
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.