Consent for Orgasm Shot® / O Shot® Procedure

(Vaginal Submucosal/Suburethral, Clitoral, and/or Labial Injection of Platelet Rich Plasma)

And Administration of Anesthesia

A. CONSENT FOR ORGASM SHOT®/O SHOT® PROCEDURE
I have received information about my condition, the proposed treatment, alternatives, and related risks.

This form contains a brief summary of this information. I have received an explanation of any unfamiliar terms and have been offered the opportunity to ask questions. I have not received any promise, guarantee or warranty that my undergoing the Orgasm Shot®/O Shot® procedure will achieve a particular result. I fully understand that individual results do vary, and that PRP SKINCARE & LASER CENTRE LTD. and Dr. Patrick Yam assumes no responsibility for failure to achieve a desired result. I understand I may refuse consent and I GIVE MY INFORMED AND VOLUNTARY CONSENT to the proposed procedures and the other matters shown below. I also consent to the performance of any additional procedures determined in the course of a procedure to be in my best interests and where delay might impair my health.

1. I authorize Dr. Patrick Yam to treat my condition, including performing further diagnosis and the procedures described below, and taking any needed photographs for proper documentation in my medical record.

2. I understand the proposed Orgasm Shot®/O Shot® procedure(s) to be: a procedure for vaginal, labial, and clitoral rejuvenation, using blood-derived growth factors (platelet-rich fibrin matrix (PRFM), platelet-rich plasma (PRP) injections.

3. I understand the potential risks associated with the proposed procedure(s) to be:
Bleeding; Infections; Urinary retention; No effect at all; Allergic reactions

Constant awareness of the G-Spot; A sensation of always being sexually aroused; Constant vaginal wetness; Mental preoccupation of the G-Spot; Alteration of the function of the G-Spot; Sexual function alteration; Hematoma; Urethral injury; Urinary retention; Hematuria (blood in urine); UTI (Urinary Tract Infection); Urinary Urgency (constant urge to urinate); Urinary Frequency Increased/worsening nocturia (waking up several times at night to urinate); Change in urinary stream; Urethral vaginal fistula (hole between urethra and vagina); Vesico-vaginal fistula (hole between bladder and vagina); 
Dyspareunia (Painful intercourse); Need for subsequent surgery

Alteration of vaginal sensations; Scar formation (vaginal); Urethral stricture (abnormal narrowing of the urethra); Local tissue infarction and necrosis; Yeast infections; Vaginal Discharges; Spotting between periods; Bladder Pain; Overactive Bladder (OAB); Bladder Fullness; Exposed Material; Pelvic Pain;
Pelvic Heaviness; Erosions; Fatigue

Damage to nearby organs including bladder, urethra and ureters; Alteration of bladder dynamics; Post-operative pain; Prolonged pain; Intractable pain; Alteration sexual response; Failed procedure;

Varied results; Psychological alterations; Relationship problems; Sex life alteration; Decreased sexual function; Possible hospitalization for treatment of complications;

Lidocaine or Xylocaine toxicity; Anesthesia reaction; Embolism

Depression; Reactions to medications including anaphylaxis; Nerve damage; 
Permanent numbness; Slow healing; Swelling; Sexual dysfunction; Allergy;
Nodule formation

4. I also understand that there may be other RISKS OR COMPLICATIONS, OR SERIOUS INJURY from both known and unknown causes. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me concerning the risks of the procedure.

5. I understand that the use of PRP in this procedure is an “off-label” use, and no promise or representation, guarantee or warranty regarding its use, benefit or other quality is made. I understand the alternatives to the proposed procedures can include the following: Do nothing; energy device (e.g. laser); pelvic physiotherapy; Kegel exercises; surgery (e.g. urethral sling, mesh implant).

CONSENT FOR ANESTHESIA
When local anesthesia and/or sedation is used by the physician: I consent to the administration of such
local anesthetics as may be considered necessary by the physician in charge of my care. I understand that the risks of local anesthesia include: local discomfort, swelling, bruising, allergic reactions to medications, and seizures from lidocaine or xylocaine.

B. PATIENT CERTIFICATION:
By signing below I state that I am 18 years of age or older, or otherwise authorized to consent. I have read or have had explained to me the contents of this form. I understand the information on this form and voluntarily give my consent to what is described above and to what has been explained to me.