STEM CELL PROCEDURE CONSENT FORM

Patient’s Name:
File No.:
DOB:
Mobile Number:
Visit Date:
Registration Time:
Doctor Name:

PRE-INSTRUCTIONS::

• Patients with blood diseases are contradicted to undergo STEM CELL injection.
• Patients must stop the following 3 days prior to the procedure:
• Aspirin, brufen, sabofen, multivitamins, vit. e & green tea

SIDE EFFECTS:

• Pain or burning sensation
• Minimal swelling for 1 to 2 days
• Possible bruise for 2 to 14 days
• Redness
• Possible peeling and pigmentations
• Diabetic patient may experience delayed wound healing on the punctured sites
• Risk for infections due to multiple punctured sites so Fucidin and Bactroban ointment or cream must be applied 3x a day for 5 to 10 days post PRP injection.
• There is no risk of allergic reaction but may develop allergy due to local anesthesia.
• Visible result will not be immediate

POST INSTRUCTION:

You can apply makeup once the wound had healed usually 5 to 10 days. If you want to apply earlier, make sure to use new sponges or brushes. • I certified that I have read and understand the contents of this form and do realize the side effects and limitations involved. I hereby authorized my doctor to perform STEM CELL and relieve my Doctor of the responsibility of any complications.

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.

Patient Name & Signature :