A. CONSENT FOR VAMPIRE FACIAL® PROCEDURE I have received information about my condition, the proposed treatment, alternatives, and related risks. This form contains a brief summary of this information. I have received an explanation of any unfamiliar terms and have been offered the opportunity to ask questions. I have not received any promise, guarantee or warranty that my undergoing the Vampire Facial® procedure will achieve a particular result. I fully understand that individual results do vary, and that Halo Med Spa and its staff assumes no responsibility for failure to achieve a desired result.
I understand I may refuse consent and I GIVE MY INFORMED AND VOLUNTARY CONSENT to the proposed procedures and the other matters shown below. I also consent to the performance of any additional procedures determined in the course of a procedure to be in my best interests and where delay might impair my health.
1. I authorize Halo Med Spa staff to treat my condition, including performing further diagnosis and the procedures described below, and taking any needed photographs.
2. I understand the proposed Vampire Facial® procedure(s) to be: a microneedling facial procedure for rejuvenating the skin of the face using blood-derived growth factors platelet-rich fibrin matrix (PRFM), platelet-rich plasma (PRP) injections.
3. I understand the risks associated with the proposed procedure(s) to be:
No effect at all
Alteration of facial features
Need for subsequent surgery
Local tissue infarction and necrosis
Damage to eyes, ears, nose, mouth
Possible hospitalization for treatment of complications
Reactions to medications including anaphylaxis
4. I also understand that there may be other RISKS OR COMPLICATIONS, OR SERIOUS INJURY from both known and unknown causes. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me concerning the risks of the procedure.
5. I understand that the use of PRP in this procedure is an “off-label” use, and no promise or representation, guarantee or warranty regarding its use, benefit or other quality is made. No representations that the use of this product and this procedure is approved by the FDA or any other agency of the federal or state government is made. I understand the alternatives to the proposed procedures and the related risks to be: do nothing. CONSENT FOR ANESTHESIA When local anesthesia and/or sedation is used by the physician: I consent to the administration of such local anesthetics as may be considered necessary by the physician in charge of my care. I understand that the risks of local anesthesia include: local discomfort, swelling, bruising, allergic reactions to medications, and seizures.
B. PATIENT CERTIFICATION: By signing below I state that I am 18 years of age or older, or otherwise authorized to consent. I have read or have had explained to me the contents of this form. I understand the information on this form and give my consent to what is described above and to what has been explained to me.