Consent Treatment of PDO/PCL/PLA (Polydioxanone) Suture Threads
Sign the consent form below: $400
(Please note that any cancelation must be made at least 7 days prior to the course in order to receive a refund. Any cancelations made after that time will not qualify for a refund.)
Thread Lift is effective in most cases; no guarantees are made that a specific patient will benefit from this procedure. Additionally, the nature of this cosmetic procedure may require a patient to return for multiple visits to achieve desired results or to determine whether Thread Lift may not be completely effective at treating a particular concern. This consent for and treatment is effective for (1) year from the date of execution unless revoked by the patient in writing.
PDO/PCL/PLA threads are FDA approved for FACIAL REJUVENATION. Currently, PDO threads are not FDA approved for rejuvenation of the body, however the material the PDO/PCL/PLA threads are made of are FDA APPROVED. These PDO/PCL/PLA aesthetic duration is from 18-24 months.
By signing this consent, I understand if I choose to have PDO/PCL/PLA threads used for OTHER THAN facial rejuvenation, I am aware the FDA has not approved these threads for rejuvenation of the body.
DISCLOSURE: Denise Merdich, APRN is a Consultant/Trainer for Les Encres distributors of the PDO, PCL, and PLA threads used in her practice.
POSSIBLE RISKS and SIDE EFFECTS
1. DISCOMFORT: Some discomfort may be experienced during treatment. I give permission for the administration of the anesthesia when deemed appropriate.
2. SCARRING: PDO Thread Lift for Mid-Face. Threads are inserted via a small acupuncture type needle; it may take a few days to heal. A scar at entry point is rare, but is always a possibility when entering the skin.
3. BRUISING, SWELLING, INFECTION: With any minimally invasive procedure, bruising or swelling of the treated area may occur. Additionally, skin infection can occur even with appropriate infection control measures.
4. BLEEDING: It is possible, though not common, to experience a bleeding episode during or after the procedure. Should bleeding occur, it may require treatment to drain accumulated blood (hematoma). Do not take aspirin, aspirin based products or anti-inflammatory medications (Advil, Motrin, Ibuprofen) for ten (10) days after treatment, as this may contribute to a greater risk of bleeding.
5. DAMAGE TO DEEPER STRUCTURES: Deeper structures such as nerves, blood vessels and muscles may be damaged during the course of this 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: in very rare cases, local allergies to tape, suture material, topical preparation or anesthesia have been reported. Systemic reactions, which are more serious, may result from drugs used during the procedure and/or prescription medications. Allergic reactions may require additional treatment.
7. ANESTHESIA: Local topical anesthesia and injectable 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 remote possibility of the treatment area becoming lighter or darker in color than the surrounding skin. This is usually temporary, but on occasion, may be permanent. Appropriate sun protection is very important and recommended.
9. PARTIAL LAXITY CORRECTION: Although PDO Threads will give some improvement in laxity, they may not correct all 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, as well as any activity involving overuse of the muscles of the face, such as chewing gum.
11. CONTRAINDICATIONS: Any allergy or foreign body sensitivities to plastic biomaterials.
12. OTHER: Slight asymmetry, redness, visible thread(s) may require additional treatment and or the removal of the thread(s).
I understand that no warranty or guarantee has been made to me as to 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, acknowledge and consent to the procedure with the knowledge of these risks.
By registering, paying and attending the AESTRA Institute course, you understand that you may be photographed, filmed or videotaped and you expressly give the AESTRA Institute, its owners, agents and principals the right to take pictures and/or recordings of you and use your likeness, image, photo without compensation, for broadcast, display, and exhibition in any medium for purposes of advertisement and education and to put the finished pictures /recordings to any use without limitation. You further expressly release AESTRA Institute from any or all claims or actions arising out of or resulting from any use of your image. However, the AESTRA Institute shall not be obligated to use your image.
***By consenting to this treatment, I agree, affirm and represent that I am waiving my right to seek any recovery for any damages that occur as a result of receiving this treatment whether such damages are as the result of an inherent risk or latent or unintended risk including any damages that may occur which are not the result of a known or expected risk. I waive any and all recovery for damages of any kind whatsoever.***
I have been informed and I understand that the practitioners who will perform this procedure may or may not be licensed to practice in the state of Florida. I have been informed and understand that Aestra Institute and Denise Merdich have not reviewed or investigated whether the practitioners performing this procedure have appropriate licensure within the state of Florida. Despite knowing that the practitioner(s) performing my procedure may or may not be licensed in Florida, I am voluntarily giving consent for the practitioners who may be licensed in other states to practice medicine, nursing, advanced registered nurse practitioners and physician's assistants to perform the procedure on me.
Your All set! Thanks for signing, See you at the course