PDO Thread Lift Consent Form

Please fill out the following form
in order to participate in our activity.

arrow&v
Are you currently in good health?
cardiac pacemakers, implanted defibrillators, implanted neurostimulators
drug pumps
Do you carry a warning card, an EpiPen, or have you ever had an anaphylaxis reaction?
malignant tumor
Fever
sensitivity or allergy to latex
haemorrhagic conditions
anticoagulation therapy
heart disorders
epilepsy
Are you currently under a specialist, hospital or doctor’s care
areas of the skin which lack normal sensation
Do you use ANY medication, herbal/natural supplements or topical creams on a regular basis
Do you have ANY allergies to medications, food, latex, or other substances
Have you had any cold sore breakouts (oral herpes) in the past year
Do you have a history of Keloid Scarring
Any blood-borne diseases
A stroke or any other blood pressure problems
Any neurological conditions such as epilepsy, Bell’s Palsy, MS, Chorea or Myasthenia Gravis
Allergic to latex, antibiotics, foods, drugs/substances
Any recent vaccinations, cortisone injections or steroids
Replacements, implants, operations, X-rays recently
Do you suffer with Acne, or have you taken medication for Acne in the past 6 months
Do you have ANY current or chronic medical illness, including: Myasthenia Gravis, Amyotrophic Lateral Sclerosis or any other Neuromuscular disorders
Do you have an autoimmune disease
Jaundice, Hepatitis, Liver or Kidney disease
Have you ever had eyelid or facial surgery
Asthma, Eczema or other allergic disease
AIDS/HIV
Deep skin peeling
Have you previously received BOTOX/ DERMAL FILLER injections
Are you, or could you be pregnant
Are you going through IVF
Are you breastfeeding
Taking medicines, pills, tablets, ointments or inhalers
Use therapies or supplements such as St. John’s Wort?
Do you bruise or bleed easily
Any circulative problems or varicose veins
Any auto-immune disease, including lupus
Any endocrine disorders? (diabetes, thyroid)
Do you follow a healthy diet?
I hereby authorize TOA Clinic or any delegated associates to perform PCL/PDO thread Lifting Treatment. I understand that this procedure is purely elective. What to Expect from the treatment: PDO / PCL thread treatment is excellent in not only the lifting effect but also in facial rejuvenation as PDO thread therapy uses an absorbable monofilament thread of polydioxanone in a free floating way and COG threads which are anchored to tissue for a more intensive lifting effect. The physiological response that occurs by inserting thin PDO / PCL sutures is an inflammatory foreign body reaction that results in collagen formation surrounding the implanted threads. The implanted threads can serve as a scaffold for the collagenous proliferation. It is known that the immediate results are due to the improved blood flow, lymph improvement and adjustment of tensed muscles. After the suture is absorbed (within 180 days after insertion) into the skin the so-called vector of pull is formed, which is actually fibrotic (scar) tissue that maintains the lift long after the suture has been absorbed. Needles with sutures are inserted and the sutures are implanted in the skin. While inserting and extracting the needles, you feel a prickling sensation. Your practitioner will apply a topical anaesthetic to your skin prior to treatment to reduce any pain and discomfort and if needed, nerve blocking can be done with lidocaine + epinephrine in general. You should ask what kind of anaesthetic will be used and should inform the practitioner if you are allergic to the type of anaesthetic product.
After treatment, inflammation can be caused (patients who tend to have inflammatory diseases such as cellulitis, shingles are advised to notify beforehand.) During treatment, bleeding may occur but stops shortly The chosen procedure can cause capillaries/veins to break causing bruising during the treatment. This lasts approximately one week. Patients who have haemostasis disabilities due to such as platelet disorders, metabolic disorders of vitamin K or taking thrombolytic agents are advised to notify beforehand. The chosen procedure above can cause pain or paresthesia which lasts for approximately one week after treatment as lymph nodes or nerves are stimulated during the treatment. In serious cases, paresthesia can be permanent. Patients with skin types requiring extra attention (keloid skin, idiosyncratic skin type, having scars which never go away, having skin resurfacing treatment) are advised to notify beforehand. Please contact us if you experience excessive redness, swelling, pain as these symptoms might indicate an infection. Threads can come out of the skin and this can cause an infection. If any thread is seen on the skin, attach a plaster to the site and visit the practitioner immediately to remove the thread. The satisfaction of all skin treatments is strongly influenced by personal and subjective judgement. Accordingly we advise you to make the treatment decision after having a detailed consultation. Lack of permanent result - thread treatment will not completely or permanently remove wrinkles or sagging skin. It is important that your expectations be realistic and understand the procedure has its limitations. Additional procedures may be necessary to achieve the desired effect. Unsatisfactory result - although rare from thread treatment, there is a possibility of a poor result depending on the regenerating ability of the patient. thread treatment may induce undesirable results and you may be disappointed with the final results.
Contraindications I understand the following contraindications listed below and will notify my practitioner if any of the following apply to me: Skin cancer High blood pressure Herpes infection Thyroid problem Diabetes Hereditary disease Emotional or neurological disorders, e.g. seizures (epilepsy), paralyses HIV, hepatitis, rheumatoid arthritis or other auto-immune diseases Medication on Painkillers, coagulation inhibitors((NSAIDS, ASA, Coumadin/Warfarin), antibiotics, blood thinner, steroids, muscle relaxants (e.g. aspirin, ibuprofen) Pregnancy and lactation Hormonal imbalance Phobia about blood or needles Active acne Broken veins (where) Recent ablative dermal procedures such as chemical peel, laser, botox, permanent filler procedure Allergies or hypersensitivity - e.g. hay fever, asthma, hypersensitivity (lidocaine, painkillers, anaesthetics, foods, medications, plasters) Rosacea / Eczema / Psoriasis / Dermatitis Roaccutane within the past year Actinic (solar) keratosis Keloids / Hypertrophic scars Recent use of some topical rx. Allergic to stainless steel Hormone Replacement Therapy Cardiac disease/abnormalities Chemotherapy or radiation Prone to bruising Scleroderma Vascular lesions (hemangiomas)
Complications The following complications may occur after the treatment but your practitioner will follow proper procedures to prevent these and will endeavour to manage the complications without any delay following your prompt notice and action. Minor side effects Facial asymmetry / Ecchymosis & Hematoma / Erythema / Edema / Infection / Skin dimpling or skin irregularities / Thread migration and protrusion / Palpable threads ends with pain Rare side effects Parotid gland / duct rupture / Nerve damage / Scar formation in the entry points / Granuloma / Chronic foreign body reaction
Post-treatment instructions An ice pack can be used to reduce swelling and bruising. DO NOT TAKE ANTI INFLAMMATORIES. If needed, wear a facial garment during night to fix the face. While sleeping, pay attention not to move too much. On the day of treatment, Keep the head high and to prevent swelling. For the first week, try to eat tender food rather than food requiring excessive use of the jaw 14 days after treatment, excessive physical activity should be avoided. All the actions which can cause inflammation such as sauna, taking a bath and drinking alcohol are prohibited for up to a week. Up to 7 days after treatment, it is recommended that excessive facial movement (yawning, yelling, singing, etc.) is avoided. Up to 3-4 weeks after treatment, it is recommended that all the exercises which can shrink the muscles of facial expression by involuntary grimacing (golf, badminton, tennis, etc.) and facial massage are avoided. Avoid direct sun and heat. This includes simple day to day tasks such as gardening, cooking over a hot stove for a long period of time, sitting next to a bonfire or fireplace, etc. 2 weeks Use a physical sunscreen. Sun care products should be applied no less than every 30 to 90 minutes. Do NOT go outside without sun protection (even on a cloudy day). Sleep on your back with your head elevated for 2 weeks. Excessive alcohol and smoking may effect the final result The benefits and risks of this procedure have been explained to me, and I accept these benefits and risks. The nature of my medical or cosmetic condition has been explained to my satisfaction, as have been any substantial or significant risks of harm. I am also aware of and accept the risk of rare and unforeseen complications which may not have been discussed and which may result from this treatment. I have had the opportunity to ask questions and seek clarification of this procedure and its alternatives, including no treatment, and my questions have been answered satisfactorily. I have taken a copy of this form for my information and aftercare. I consent to the use of my anonymised pictures for marketing purposes.

Thanks for submitting!