GCell Autologous Tissue Suspension Procedure

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Consent Form for GCell Autologous Tissue Suspension

I understand that Gcell/Autologous Tissue Suspension is a treatment whereby the Doctor will inject the local anesthesia and harvest the 4 or 5 Hair follicle/micrograft from the patient’s using 3mm punch biopsy own Hair follicle/micrograft will process to the Gcell device then injected back into the problem area to stimulate new collagen production and to energize the cells into rejuvenating themselves. The same process is also done for the hair to reduce hair loss and improve the hair growth.

I have been explained about maintenance treatments that may be required after completion of treatment. The total number of treatment sessions may vary among individuals. Exact number of sessions cannot be predicted.

No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. On rare occasion there may be a patient who does not respond to treatment.

I was also informed about the other alternative methods as well as their benefits and disadvantages. I understand that for ideal results, this procedure can be combined with Micro needling, Platelet Rich Plasma etc.

I understand the following side effects and complications may be experienced like little pain, mild to moderate swelling which may subside in 3 to 7 days, redness.

I understand that variable results are seen due to the patients’ lifestyle, medical profile, and age, extent of hair loss, and genetic factors.

My medical history regarding herpes, allergy, acne, keloids, diabetes, and autoimmune disease, treatment with anticoagulants, NSAIDS, blood thinners or corticosteroids is disclosed correctly. I am not pregnant or breast-feeding.

Topical, local anesthesia is required in few patients. I am ready to take the appropriate form of anesthesia.

By signing below, I acknowledge that I have read the adverse reactions above and I feel that I have been adequately informed of the risks of GCell Autologous Tissue Suspension treatment.

Before each treatment, I will inform the doctor if I have taken any new medications since my last treatment. I also agree to comply with the recommended aftercare instructions.

I hereby release Dr. and its designated staff from liability associated with the above procedure. My questions regarding the procedure have been answered satisfactorily.

I authorize Dr. and his/her designated staff to perform GCell Autologous Tissue Suspension treatment on my body.

The payment and fee structure are informed to me. I am ready to pay per sitting or package basis. [Package if opted for includes minimum number of sittings and I have to pay accordingly if more sittings are required.

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.

 

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.

Patient Name & Signature :