PRP TREATMENT CONSENT FORM

Patient Name:

Date of Birth:

Procedure Date:

1. Consent for Treatment

I authorise Dr. Maria Mackey and her appointed assistants to perform the following procedure: Thread Lift. I confirm my understanding that this treatment involves the insertion of specialised threads to achieve skin lifting and rejuvenation, using materials and techniques approved by the Therapeutic Goods Administration (TGA).

2. Explanation of Procedure

The Doctor has provided detailed information about:

  • The purpose, benefits, and expected outcomes of the procedure.
  • The type of threads used, their composition, and the insertion technique.
  • The potential risks, temporary side effects, and complications.
  • The recovery process and aftercare requirements.

Alternatives to this procedure and their associated benefits and risks

3. Acknowledgement of Risks and Complications

I understand that while this procedure is generally safe, potential risks include but are not limited to:

  • Common Risks: Swelling, bruising, redness, and mild discomfort.
  • Rare Complications: Infection, thread migration or extrusion, asymmetry, nerve injury, granulomas, nodule formation, scarring, or delayed healing.
  • Other Factors: Individual responses may vary, and additional treatments may be required to achieve desired results
4. Realistic Expectations

I acknowledge that:

  • The final results of the procedure may take up to eight weeks to appear.
  • Outcomes are influenced by factors such as skin type, age, and healing response.
  • Additional adjustments may be necessary for optimal results.
  • No guarantee has been provided regarding the specific outcomes of the procedure.
5. Anaesthesia

I consent to the administration of anaesthesia (local or topical) if deemed necessary for my comfort and safety. I understand the risks associated with anaesthesia, including allergic reactions.

6. Medical History Disclosure

I have provided the Doctor with my complete medical history, including:

  • Any current illnesses, allergies, or skin conditions.
  • All medications, supplements, and treatments I am currently using.

I understand that withholding information may increase the risk of complications.

7. Risks and Complications

I understand that no procedure is without risks. Potential side effects and complications of a thread lift include, but are not limited to:

  • Swelling, bruising, or redness.
  • Asymmetry or uneven results.
  • Infection or delayed healing.
  • Scarring or thread migration.
  • Granulomas or nodule formation.
  • Temporary or permanent nerve injury.
8. Infection Prevention

I understand that:

  • Antibiotics may be prescribed to reduce the risk of infection.
  • Failure to take antibiotics as directed or follow aftercare instructions increases my risk of infection.

In the event of any signs of infection (e.g., redness, swelling, pain, or fever), I must contact the clinic immediately.

9. Post-Treatment Care and Follow-Up

I commit to attending all scheduled follow-up appointments and adhering to the aftercare plan provided by the clinic. I understand that post-procedure care is essential for achieving the best possible outcome.

10. Management of Complications

In the event of complications, I consent to any necessary interventions, including the removal of threads or additional corrective procedures. These may incur additional costs.

I consent to the removal of threads if deemed medically necessary, understanding that this may be a separate procedure.

11. Observers During Procedure

I consent to the presence of observers in the operating room for medical education purposes:

Yes
No
12. Tissue and Device Disposal

I consent to the disposal of any removed tissue or medical devices per regulatory guidelines.

13. Photography and Medical Records

I consent to photographs being taken for treatment documentation. These photographs will be securely stored and not used for other purposes without my express written consent.

Patient Acknowledgment

Please INITIAL the following statements to confirm understanding:

  • The procedure has been explained to me in clear terms.
  • I understand the treatment or procedure proposed.
  • I understand there are alternative treatments or procedures.
  • I understand the risks associated with this procedure.
  • I will contact the Doctor if I have any concerns.
Informed Consent

I have read and understood this consent form. I have had sufficient time to consider the information provided and am satisfied with the explanation of the procedure and associated risks. I voluntarily give my informed consent for the thread lift procedure.

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