PDO Threads Consultation/Consent Form | Aesthetics Forms Portal - Paperless Mission Control

PDO Threads Consultation and Consent Form

Model Details

Full Name: *

Full Name: *

Contact Number: *

Date of Birth: *

Email: *

Medical History

Please list: *

Are you currently taking any medications (oral or topical)? *

Please list: *

Are you currently receiving any medical treatment? *

Do you have any allergies? *

Please list: *

Are you (or is there a possibility you may be) pregnant, or are you breastfeeding? *

Have you been unwell recently? *

Which of the following were you unwell with? *

Please provide more details: *

Do you have any surgery planned in the next 6 months? *

Please provide more details: *

Do you have any cutaneous (skin) infection or inflammatory problems (e.g. herpes/cold-sores, acne etc.)? *

Please provide more details: *

Are you taking any steroids, aspirin or anticoagulant (i.e. warfarin, apixaban etc.)? *

Please provide more details: *

Do you have any history of anaphylactic shock or severe allergic reactions? *

Please provide more details: *

Do you tend to develop hypertrophic scarring? *

Please provide more detail: *

Have you previously had any PDO Threads? *

Which treatment did you receive, what areas were treated and when? *

Have you previously had any sensitivity to PDO - Polydiaxanone suture material, lidocaine or local anesthetics? *

Please specify: *

Are you undergoing any dental work or have any dental work/hygienist planned? *

Please specify: *

Do you have any metal plates in your face? *

Please provide more detail: *

Have you taken any Aspirin, Ibuprofen, Fish Oil, Vitamin E in the last five days? *

Please specify: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

PDO Threads Treatment

The PDO (polydioxanone) Thread Lift and Smoothing procedure uses absorbable surgical sutures placed into the subdermal layer of the skin to initiate collagen production.

A thread lift is a nonsurgical cosmetic procedure that lifts and tightens your skin for a younger look. A thread lift also stimulates your body’s collagen production. Collagen creates firmer, more supple skin and naturally diminishes with age. A thread lift procedure has a quick recovery with minimal complications.

The procedure can result in increased firmness and elasticity of the skin in the treated area. The nature of this 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.

*PDO Threads and NovaThreads PDO Thread are FDA approved threads for “minimally invasive”, non-surgical lifting of the face neck. Other suture ("thread") types and brand names may be FDA approved materials are not FDA approved specifically for Thread Lift treatments. Sutures that maintain FDA material approval, but are not approved for Thread Lift treatments are considered "off-label" use.

What To Expect During Treatment: Your treatment provider will begin by measuring and mapping (drawing) out the thread placement on your skin with a surgical marker. An injectable or cream local anesthetic is used on treatment area prior to beginning thread treatment, but you may still experience mild discomfort, especially when threads are tightened. Threads are then introduced into the skin with a needle or blunt-ended cannula and are positioned and pulled to help to tighten sagging skin and add definition to the face. The threads will dissolve on their own over the next 6-18 months. Although the skin is instantly lifted after a thread lift procedure, most patients see the final lifting effect after about 14 days. Duration of treatment is dependent upon treatment location but generally lasts between 60-120 minutes. You may experience a slight stinging sensation with cannula placement and a tugging sensation when the thread is tightened. There is no expected downtime with Thread Lift treatments. Results are temporary; maintenance treatments may be necessary to maintain desired results.

What would you like the treatment to improve or change about your appearance? *

I understand this is an elective procedure and I hereby voluntarily consent to treatment with PDO suture threads for skin rejuvenation and collagen production, lifting and tightening of the skin to help establish proper lip and smile lines and improved esthetics. The procedure has been fully explained to me. I also understand that any treatment performed is between me and the trainer and student in training who is treating me and I will direct all post-operative questions or concerns to the treating trainer. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure and I understand that no guarantees are implied as to the outcome of the procedure. I also certify that if I have any changes in my medical history I will notify the trainer and academy who treated me immediately. *

YES

Possible Risks and Complications

Before undergoing this procedure, understanding the risks is essential. No procedure is completely risk-free.

The possible risks of PDO Threads include, but are not limited to:

Discomfort: Some discomfort may be experienced during treatment.
Scarring: May cause scarring; sutures are inserted using a small needle, which must heal. A scar at the entry point may occur.
Bruising, Swelling, Infection: With any minimally invasive procedure, bruising of the treated area may occur along with the potential for swelling. Bruising and swelling are very likely to occur. Infection is rare, but with any injection or incision into the skin, the possibility exists.
Bleeding: You may experience some bleeding during the procedure. A 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.
Partial Laxity Correction: PDO Lift may not correct all your facial laxity or sagging.
Delayed 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 removal of the sutures.

Post Treatment & Results

You may see visible results immediately after treatment, but expect to see continued results over the next several weeks. Over the next 6-18 months, your body will begin to dissolve the suture threads. Results can last 1-3 years, depending on the individual and desired outcome.
Continued discomfort may include a pulling sensation or irritation when moving your facial muscles for the next 1-4 weeks.
If eruption of suture thread or signs of infection occur: Call Office.
- Signs/Symptoms of infection: Increased redness/pain/warmth or formation of pustules at treatment site.
Sometimes, a slight depression or skin irregularity may appear at the insertion points. These typically disappear a few days after treatment.

Aftercare Advice

The goal of aftercare is to encourage optimal treatment results. It can also minimize the risk of bruising and spreading to other areas. Follow the aftercare advice provided for optimal results.

PLEASE DO NOT:

1. Do NOT massage, apply pressure, or sleep face-down on the treated area for 3 weeks after treatment. Do not receive facial, face-down massages, or facial aesthetic treatments for 4 weeks.

2. Do NOT have Radio-frequency, IPL, Laser or heat treatments near the treated area for 10 weeks.

3. Do NOT engage in running, heavy lifting, or vigorous exercise for 3 weeks post-treatment. Avoid excessive sweating during first week to help keep insertion sites clean.

4. Do NOT submerge suture areas in a bath, Jacuzzi, swimming pool, or body of water for 14 days.

5. Do NOT take Advil, Aspirin, Aspirin containing products (including Excedrin), Vitamin E, Ginger, Ginko, Bilboa, Ginseng, and Garlic for 1 week since this may increase the risk of bruising. If you are taking RX aspirin, warfarin, or other anti-coagulants, please continue to do so, but doing so may cause excessive bruising,

6. Do NOT apply makeup for at least the first 24 hours after treatment.

PLEASE DO:

1. Sleep with your head elevated at least 30º for the first three nights to help reduce swelling.

2. Limit your facial movements for at least 2 weeks, which includes avoiding: excessive chewing, sucking straws, oral sex, talking, yawning, smiling, yelling, and opening mouth wide, etc. during this period of time. Avoid dental treatments and procedures for 2-3 weeks post-treatment.

3. Gently wash the treated area daily, but do not rub or massage for 2 weeks.

4. Cold compresses may be used 20 minutes on 20 minutes off to reduce swelling 2-3x per day during the 1st 1-2 days if needed.

5. Understand it is not uncommon to experience the following for the next 1-7 days: discomfort, bruising, mild inflammation, redness, soreness, and mild swelling. If you experience an increase in these symptoms after the first 72 hours, please call the office for a follow-up. You may apply cold compresses, take acetaminophen (Tylenol), or use Arnica cream/supplements to reduce swelling or discomfort.

6. A soft diet is recommended for the first 3 days post-treatment. Stay hydrated and chew slowly.

Please click the box to confirm: *

I have read and understood the aftercare advice given to me on this form.

Consent

I accept that any treatment I am going to receive is at my own risk.

I certify that I have read, fully understood, and completed this form to the best of my knowledge.

I understand that failure to disclose information requested above may result in adverse side effect(s), unknown because of this to which I accept full liability/responsibility.

The treatment(s) and possible side effect(s) have been fully explained to me.

I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request.

I accept that if I am not satisfied with the treatment I will inform the academy immediately.

I fully understand the above and consent to receive PDO Threads.

Signature: *

Tap or click on the signature above to sign

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