• Consent for Orgasm Shot® / O Shot® Procedure

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

    And Administration of Anesthesia

  • Rationale

    I have been advised that PRP is used to stimulate the body to repair and regenerate weak and damaged connective tissue which are believed to contribute to pain, altered sensation, and decreased pelvic floor support of the urethra. The procedure requires the injection of PRP derived from a small sample of my own blood, according to standard preparation techniques.  The injection is localized to the area of concern.
  • 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.

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