The Orgasm “O” Shot, is a non-surgical treatment that pledges to increase sexual arousal and rejuvenate the vagina.

Patients report stronger and more frequent orgasms, increased natural lubrication, and greater arousal after having the procedure.

I hereby give my voluntary consent to Aesthetician/Doctor/Surgeon and whomever works under his/her supervision) to perform the following clinical procedure .

I recognize during the procedure and medical treatment or anesthesia, unforeseen conditions may necessitate different procedures than those above. I therefore authorize the above physician and assistants to perform such other procedures that are in the exercise of his or her professional judgment necessary and desirable. The authority granted under this paragraph shall include all conditions that require treatment and are not known to my physician at the time of the procedure has begun.

I consent the administration of such anesthetics considered necessary and advisable. I understand that all forms of anesthesia involve risks and the possibility of complications, injury and sometimes death.

I understand what my physician can and cannot do, and I understand there are no warranties or guarantees, implied or specific about my outcome. I have had the opportunity to explain my goals and understand which desired outcomes are realistic and which are not. All my questions have been answered, and I understand the inherent (specific) risks of the procedures I seek, as well as those additional risks and complications, benefits, and alternatives. Understanding all of this, I elect to proceed.

Risks and Complications

It has been explained to me that there are certain inherent and potential risks and side effects to any invasive procedure, and in this specific instance such risks include but are not limited to:

• DISCOMFORT – Some patients feel a warmth or mild burning sensation from each laser pulse, which may produce a slight discomfort. This mild burning sensation is like a sunburn and may last for up to 24 hours post-treatment.
• HERPES SIMPLEX- Herpes simplex eruptions may occur in rare cases in a treated area that has previously been infected with the virus. This reactivation can be avoided by taking an antiviral medication prior to the procedure, which will be prescribed from our clinic prior to the treatment.
• REDNESS/SWELLING/BRUISING – Immediately after the treatment, your skin might be red and feel hot. This is temporary. The first day after the treatment, your treated area might be swollen with slight redness for the next few days. After the first day, the redness can be camouflaged with opaque makeup. Cold packs can reduce these symptoms.
• ITCHING/DRY SKIN – Treatment may result in itching and/or dry skin.
• RED RASH/BUMPS – Red rash/bumps may appear after treatment. This resolves with time.
• WOUNDS – Treatment can result in burning, blistering, or bleeding of the treated areas. If any of these occur, please call our office.
• INFECTION – Infection is a possibility whenever the skin surface is disrupted, although proper wound care should prevent this. If signs of infection develop, such as pain, heat, or surrounding redness, please call our office.
• BLISTERING OR SCARRING – Blistering occurs occasionally and needs to be reported to the clinic for additional post-care instructions. Scarring is very rare and can be avoided by following all the post-treatment instructions carefully.

Photographs

I authorize the taking of clinical photographs and their use for scientific purposes both in publications and presentations.

YES

NO

Pregnancy, Allergies & Neurologic Disease

I am not aware that I am pregnant, and I am not trying to get pregnant. I am not lactating (nursing). I do not have any significant neurologic disease including but not limited to Myasthenia Gravis, Multiple Sclerosis, Lambert-Eaton Syndrome, Amyotrophic Lateral Sclerosis (ALS), and Parkinson’s. I do not have any allergies to the toxin ingredients or to human albumin.

Financial Responsibilities

I understand and agree that all services rendered to me are charged to me directly and that I am personally responsible for payment. The fees charged for this procedure do not include any potential future costs for additional procedures that you elect to have or require in order to revise, optimize, or complete your outcome. Additional costs may occur should complications develop from the procedure and will also be my responsibility. In signing the consent for this procedure, I acknowledge that I have been informed about its risk and consequences and accept responsibility for the clinical decisions that were made along with the financial costs of all future treatments. I understand and unconditionally and irrevocably accept this & that all costs are NON-REFUNDABLE.

Disclaimer

Informed consent documents should not be considered all-inclusive in defining other methods of care and risks encountered.

I hereby authorize this clinic and its trained licensed designees to perform the treatments/procedure mentioned above.

1. I have received and read the INFORMED CONSENT and PRE & POST CARE INSTRUCTIONS that were explained to me, and I agree to follow all instructions, to follow up as directed, and to notify the office if any problems or questions arise.
2. I understand that there is a possibility of short-term effects such as reddening, mild burning, temporary bruising and temporary discoloration of the skin, as well as the possibility of rare side effects such as scarring and permanent discoloration. These effects have been fully explained to me.
3. I understand that the activities I will do after the surgery can negatively affect the healing process and that I have to follow the rules in a very disciplined way.
4. I acknowledge that I should not have sexual intercourse during the recovery period.
5. I understand that there may be a reaction to the suture materials used during the surgery, that the scar tissue or keloid that may occur due to these reactions or subsequent infections may appear more clearly than expected.
6. I understood the potential risks of clitoral hood reduction and other vaginal procedures such as nerve damage, hypersensitivity, or decreased sensitivity.
7. I recognize that during the course of the procedure and medical treatment or anesthesia, unforeseen conditions may necessitate different procedures than those above. I therefore authorize the above-mentioned provider to perform such other procedures that are in the exercise of his or her professional judgment necessary and desirable.
8. I consent to the administration of such anesthetics considered necessary or advisable. I understand that all forms of anesthesia involve risk and the possibility of complications.
9. The nature and purpose of the treatment have been explained to me. I understand what my provider can and cannot do, and I understand there are no warranties or guarantees implied or specific about my outcome. I have had the opportunity to explain my goals and understand which desired outcomes are realistic and which are not. I have read and understand this agreement. All my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of treatment and their risks and benefits have been explained to me
10. I understand that I have the right to refuse treatment. By signing this form, I elect to proceed with treatment.

I have read the foregoing information, or it has been read to me. I have had the opportunity to ask questions about it and any questions that I have asked have been answered to my satisfaction. I consent voluntarily to undergo tis treatment and understand that I have the right to withdraw from the procedure or treatment at any time without in any way affecting my medical care.

I confirm my understanding of:

a. The above treatment or procedure to be undertaken

b. There may be alternative procedures or methods of treatments

c. The risks associated with the treatment or procedure

I CONSENT TO THE TREATMENT/PROCEDURE MENTIONED ABOVE AND I FULLY UNDERSTAND THE TERMS AND CONDITIONS.