Edmund Fisher MD and Noam Rosines MD Inc. dba Luz Lounge Platelet Rich Plasma Consent DESCRIPTION OF TREATMENT This treatment involves the collection of your blood (approximately 10-20ml) which is then spun using a centrifuge to separate out the plasma and platelet portion. The PRP portion of your blood is then injected back into your skin to stimulate new collagen production, and/or into your scalp to re-energize your hair follicles into rejuvenating themselves. The product injected is 100% your own blood by-product (autologous). BENEFITS Along with the benefit of using your own tissue therefore eliminating an allergic reaction, there is the added intrigue of mobilizing your own stem cells for your benefit. PRP has been shown to have overall rejuvenating effects on the skin including, improving skin texture, the appearance of fine lines and wrinkles, increasing volume via the increased production of collagen and elastin and by diminishing and improving the appearance of scars. PRP has also been shown to effectively treat hair loss in some cases. Other benefits are: minimal down time, safe with minimal risk, short recovery time, natural looking results and no general anesthesia is required. CONTRAINDICATIONS While PRP use in aesthetic procedures is safe for most individuals between the ages of 25-80, there are some contraindications. Patients with the following conditions are not candidates for PRP treatments: - Acute and Chronic Infections, including active acne.
- Skin diseases (i.e. SLE, porphyria, allergies)
- Active cold sores
- Current use of Retinoids (Retin-A, Retinol, Accutane)
- History of Cancer/Facial cancer, past and present. This includes SCC, BCC and melanoma
- Chemotherapy
- Severe metabolic and systemic disorders
- Abnormal platelet function (blood disorders, i.e. Hemodynamic Instability, Critical Thrombocytopenia, etc)
- Chronic Liver Pathology
- Anti-coagulation therapy (Heparin, daily baby aspirin)
- Underlying Sepsis
- Systemic use of corticosteroids within two weeks of the procedure
- Pregnant or breastfeeding.
RISKS & COMPLICATIONS Some of the general risks and complications of Platelet Rich Plasma include: - Minor discomfort (pin prick sensation) Dizziness and feeling faint (rare) from blood draw
- Pain or itching at the blood draw/injection site for several days
- Bleeding, Bruising, Swelling and/or Infection at the blood draw/injection site
- Temporary headache
- Reaction to numbing medications
- Short lasting pinkness/redness (flushing) of the skin
- Allergic reaction to the solution
- Activation of cold sores
- Injury to a nerve and/or muscle
- Nausea/Vomiting
- Dizziness or fainting
- Temporary blood sugar increase
For hair restoration injections, additional risks and complications include: - Redness in the scalp for 2-4 days
- Hair loss (temporary) in the existing hair. This is often termed ‘shock loss.’
RESULTS Results are generally visible at 3 weeks and continue to improve gradually over the next 3-6 months with improvement in texture and tone and hair growth. Advanced wrinkling cannot be reversed and only a minimal improvement is predictable in persons with drug, alcohol, and tobacco usage. Severe scarring or hair loss may not respond to treatment. Current data shows results may last 18-24 months. Of course all individuals are different so there will be variations from one person to the next. Most people heal without any problems. However, here are some problems that you may encounter: If you are prone to getting fever blisters (herpes simplex) then you might even develop a herpes infection. You will notice that the skin becomes thickened and has a different feel. In fact you should recognize the familiar symptoms of herpes. If so then apply a suitable anti herpetic preparation. You might notice small white dots appearing on the skin. These might be simple little retention cysts (Milia) or they could be minute infected areas. Carefully but firmly wipe them away and apply an antibiotic lotion. It is a good idea to consult your doctor about this. Do not allow the white dots to remain on the skin and if you are not able to remove them yourself then please consult with your doctor. If the skin becomes painful and redder, then you may have developed an infection and you must see your doctor at once. PRP CONSENT This consent was read and signed while I was not under the influence of medications that might alter my mental capacity to understand its contents. I understand that due to the natural variation in quality of Platelet rich plasma, results will vary between individuals and that although I may see a change after my first treatment; I may require a series of up to 6 sessions or more to obtain my desired outcome. I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and that, therefore, there can be no guarantee as expressed or implied either as to the success or other result of the treatment. I am aware that the PRP treatment is not permanent as natural degradation will occur over time.
I understand that the success of the PRP procedure is dependent on the amount and quality of PRP obtained and my closely following all instructions. This includes but is not limited to, pre/post procedure activities and precautions. I understand that blood will be drawn from a vein in my arm and I may become bruised and that blood will then be placed in a centrifuge to be separated and then injected or applied topically during/after micro-needling the treatment area. Topical anesthesia will be given to reduce discomfort of the PRP injections and micro-needling. I certify that I have no known allergies to and have never had any adverse reactions to either topical or local anesthetic.
I am aware of the pros, cons and alternatives to PRP injections. I understand that PRP injections and micro-needling are part of an elective procedure. If I do not have PRP injections, I will not experience harm or negative consequences for my body. I agree that the procedure(s) recommended by Dr. Edmund Fisher and his staff of nurses are recommendations at the time of consultation. I agree these recommendations may later need to be modified depending on future developments, changes in my own goals or technology.
I understand that the aging process and hair loss is continuous throughout life for some people. I understand that additional PRP injection procedures may be needed and that some individuals would expect 1-3 sessions per year for maintaining desired results. I have read and understand all of the possible side effects and complications listed above. I accept the risks of these possible complications and consequences associated with this procedure.
I consent to having my photos taken. These include pre-treatment (‘before’) photos, photos during the procedure (‘during’) if needed and post-treatment (‘after’) photos. I understand these photos will not reveal my identity. I give consent to Lüz Lounge to use these photos in teaching and research, including teaching of doctors, nurses, trainees and the general public. I consent to having photos used for advertising purposes, which may include brochures, websites and use during pre- treatment consultations. I understand that I may withdraw my consent at any time by providing a written document stating so. However, photos will still be obtained for my chart and for purposes of documentation of treatment outcomes.
I acknowledge that I am responsible for payment of these services with no fee reimbursement regardless of procedure results. I understand the fee paid is for the procedure and not for an expected result. I understand that payment is due the day of my procedure.
I understand that I need to sleep on clean sheets or a towel the first 48 hours after treatment to avoid risk of any infection.
My consent and authorization for this elective procedure is strictly voluntary. By signing this informed consent form, I hereby grant authority to Lüz Lounge medical staff to perform Platelet Rich Plasma “aka” PRP injections to area (s) discussed during our consultation, for the purpose aesthetic enhancement and/or hair rejuvenation. I have read this informed consent and certify I understand its contents in full. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I agree to adhere to all safety precautions and instructions after the treatment. I have been instructed in and understand post treatment instructions and have been given a written copy of them. I understand that medicine is not an exact science and acknowledge that no guarantee has been given or implied by anyone as to the results that may be obtained by this treatment. I also understand this procedure is “elective” and not covered by insurance and that payment is my responsibility. Any expenses which may be incurred for medical care I elect to receive outside of this office, such as, but not limited to dissatisfaction of my treatment outcome will be my sole financial responsibility. Payment in full for all treatments is required at the time of service and is non-refundable. I hereby give my voluntary consent to this PRP procedure and release Luz Lounge, all medical staff, and specific technicians from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age and am not under the influence of alcohol or drugs. This consent form shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns. I agree, if I should have any questions or concerns regarding my treatment / results I will notify Lüz Lounge immediately so that timely follow-up and intervention can be provided
LIABILITY RELEASE: I understand that results will vary between individuals. I understand that although I may see a change after my first treatment, I may require a series of sessions to obtain my desired outcome. The procedure and side effects have been explained to me including alternative methods; as have the advantages and disadvantages. I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and that, therefore, there can be no guarantee as expressed or implied either as to the success or other result of the treatment. I am aware that this treatment is not permanent as natural degradation will occur over time. I certify that the information I have given is accurate and complete to the best of my knowledge. I hereby release Dr. Edmund Fisher and Dr. Noam Rosines and their medical staff, partners and/or associates from any legal or financial responsibility. I state that I have read (or it has been read to me) and understand this consent and I understand the information contained in it. I understand I’m getting consulted and treated by Dr. Edmund Fisher and Dr. Noam Rosines Nurse Practitioners and Registered Nurses today July 26, 2024 I have had the opportunity to ask any questions about the treatment including risks or alternatives and acknowledge that all my questions about the procedure have been answered in a satisfactory manner. July 26, 2024 STATE MEDICAL SERVICES CONTRACT All Medical treatments are performed by Edmund Fisher MD and Noam Rosines MD Inc. Medical Group, dba Luz Lounge. A signed copy of this document is to be emailed/given to the client upon request. Original is to be filed in Client’s medical records. Arbitration Agreement CD0501Y8v2 ARTICLE I: ARBITRATION Article 1.1: Agreement To Arbitrate: It is understood that any dispute as to medical malpractice by Client, including any party that would have standing to assert a claim on behalf of or in connection with services provided to Client, that is as to whether medical services rendered under this contract were unnecessary, unauthorized or lacking informed consent or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by State law, and not by a lawsuit or resort to court process except as State law provides for judicial review of arbitration proceedings. For purposes of this agreement, “Dispute” means any claim or controversy of whatever kind or nature including (without limitation) any claim or controversy regarding the formation, validity, interpretation and/or enforce ability of this agreement to arbitrate and any claim or controversy by the Client asserting loss of consortium, wrongful death, emotional distress or punitive damages. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Article 1.2: Procedure For Initiating Arbitration: Either party to this agreement may initiate Arbitration by submitting a Demand for Arbitration in writing to the other. The Demand shall contain a plain and simple statement of the nature of the Dispute and the remedy demanded. There shall be one Arbitrator who shall be a retired Judge of a court of record. The Arbitrator shall be selected by agreement of the parties on or before 30-calendar days of the date that the Demand for arbitration is deposited for delivery with a common carrier (as determined by a postmark or other equivalent writing imprinted by the common carrier). If the parties have not agreed to a selection of the Arbitrator, than either party may petition the appropriate Superior Court to appoint the Arbitrator and, consistent with CCP § 1281.6, the Superior Court shall appoint the Arbitrator, who shall have the qualifications stated in this paragraph. Article 1.3: Law Governing Arbitration; Arbitrator’s Award And Enforcement. Without reference to its choice of law rules, the Arbitrator shall apply the substantive law. The Arbitrator shall render his or her award in writing and the award shall separately state the Arbitrator’s findings of fact and conclusions of law. The Arbitrator’s award shall be binding on the parties to the arbitration and judgment on the award may be entered by a court of competent jurisdiction. Judicial proceedings to confirm, amend, or vacate the arbitration award shall also take place. To the extent permitted by law, venue for such proceedings shall be in the county (or the federal judicial district) where the services were rendered. Unless the Arbitrator shall determine otherwise, the Arbitration shall take place in the county where the services were rendered. The Arbitrator shall have the authority to hear any claim and award any remedy that could otherwise be heard or rendered by the Superior Court or a federal district court. Discovery shall proceed in accordance with State Code of Civil Procedure, §§ 1283.1, 1282.05, and, in addition, any party, may, of right, bring a motion for summary judgment or adjudication in accordance with CCP § 437c. The parties to this agreement agree to arbitrate in one proceeding all claims arising out of the same or a related incident, transaction or occurrence. Article 1.4: Small Claims Court: Notwithstanding the foregoing any party to this agreement may initiate and prosecute in the small claims division of the Superior Court any claim at law demanding an amount equal to or less than the jurisdictional limit of the small claims division. Notwithstanding applicable law, no judgment in an action initiated in the small claims division may be entered for an amount in excess of the jurisdictional limit of the small claims division. Article 1.5: Severability: If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provisions. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY MUTUAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO JURY OR COURT TRIAL. I have read and agree to the terms/conditions listed in this agreement and understand that I have the right to receive a copy of this agreement upon request. July 26, 2024
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