INFORMED CONSENT FOR COLLAGEN THREAD LIFT PROCEDURE
The PDO (polydioxanone) Threat Lift and Smoothing procedure uses absorbable surgical sutures placed
into the subdermal layer of the skin to initiate collagen production. The procedure can result in increased
firmness and elasticity of the skin in the treated area. The PDO Lift procedure is effective in most cases,
however there is no guarantee a specific patient will benefit from the procedure. The nature of cosmetic
procedure may require a patient to return for numerous visits in order to achieve the desired results or to
determine whether the treatment may not be completely effective at treating the particular condition.
Alternative Treatments: Alternative forms form of non-surgical and surgical treatment consist of surgical
facelift, Nd:YAG laser, full-face C02 laser, dermal fillers, local muscle relaxer (Botox, Dysport, Xeomin),
chemical peels or inaction. Every procedure involves a certain amount of risk. An individual�s choice to
undergo a procedure is based on the comparison of the risk to the potential benefit. Although most
patients do not experience adverse complications, you should discuss your concerns and potential risks
with your practitioner in order to make an informed decision.
Possible Risks and Side Effects Associated with PDO Threat Lift Procedure:
Discomfort: Some discomfort may be experienced during treatment. Scarring: May cause scarring; sutures are inserted using a small needle, which must heal. A scar a scar at
entry point may occur.
Bruising, Swelling, Infection:
With any minimally invasive procedure, bruising of the treat area may occur
along with the potential for swelling and is likely. Infection is rare, but with any injection or incision into
the skin, the possibility exists.
Bleeding:
You may experience some bleeding during the procedure. Hematoma or a small
blood clot may occur and may require treatment by drainage. There is a higher risk of bleeding if you have
taken any anti-inflammatory medications (Advil, Motrin, Aspirin, Ibuprofen) within the 10 days preceding
the procedure.
Damage to Deeper Structures:
Deeper structures such as nerves, blood vessels and muscles may be
damaged during the 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.
Allergic Reaction:
Allergies to tape, suture material or topical preparations have been reported. Allergic
reactions may require additional treatment.
Anesthesia:
Local topical anesthesia may be used and can involve risk of allergic reaction.
There is a possibility of the treatment area becoming lighter or darker than the surrounding skin. This is
usually temporary, but on rare occasions, may be permanent. Appropriate sun protection is important. Partial Laxity Correction: PDO Lift may not correct all your facial laxity or sagging.
Delay Healing:
Complications may ensure as a result of smoking, using a straw, or similar motions. Smoking
and similar actions are STRONGLY discouraged. Slight asymmetry, redness, visible sutures, suture
breakthrough may require additional treatment or the removal of the sutures.
Contraindications:
Any known allergy or foreign body sensitivities to synthetic biomaterials.
Additional Procedures May Be Necessary:
In some situations, it may not be possible to achieve optimal
results with a single PDO Lift procedure and other procedures may be necessary. Although peak results are
expected, there cannot be any guarantee or warranty expressed or implied on the results that may be
obtained.
The cost of the procedure may involve several charges for serviced provided. The total may include fees
charged by Enfield Royal Clinic, the cost of supplies, or laboratory tests if necessary. Additional costs may
occur should complication develop from the procedure.
I understand that no warranty or guarantee of specific result has been made to me. 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 result in a delay to one�s normal daily activities and thus economic loss.
I understand my practitioner may discover other conditions which require additional or different
procedures than planned treatment. I authorize my practitioner and his or her associates, technical
assistants and other health care providers to perform such other procedures which are advisable in their
professional judgment.
I understand my cheeks/jowls may not achieve the desired improvement anticipated.
I understand sutures may extrude, may have to be trimmed or may have to be removed in the future.
I understand the results may relax over time and additional procedures may be required.
I consent to the taking of photos before, during or after the procedure to document my progress. The
nature of the elective procedure, its risks and potential complications have been fully explained to me
along with available alternative treatments and their benefits and risks has been discussed. I understand I
have the right to refuse treatment. I have been instructed to and agree to abide by all safety precautions
and post treatment instructions and have been given a written copy. I understand no refunds will be given
for received treatment and no guarantee(s) have been given regarding the results. I release the facility,
medical staff, and other technicians from liability associated with this procedure.
This consent is voluntarily executed and shall be binding on my spouse, relative, legal representatives,
heirs, administrators, successors and assignees. I also certify that if I have any changes in my medical
history, I will notify the Enfield Royal Clinic immediately. I also state that I read and write in English. If you
have any questions or concerns, please contact our clinic.
I understand and agree that I am financially responsible for the payment I made for
that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the
date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months
period. I agree that my payment made is non-refundable or non-transferable post this period.
I declare that I have read and fully understood all points in this consent and that all of my questions were
answered to my satisfaction and I take the full responsibility of my decision in this consent.
Patient Name & Signature :
Doctor/Therapist Name & Signature :
Witness Name & Signature :
Parent or Gaurdian Name (if patient is minor) :
Date :
Consent to be photographed and published
I, , consent to be photographed and published on Social
media, by while before and after the procedure. I further authorize that the
photographs may be published for any purpose and in any form.