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Selphyl Consent

CONSENT FOR TREATMENT WITH SELPHYL

Selphyl is a system designed for the preparation of a PRFM from my own blood, which can then be injected into the treatment area.

The use, benefits and side effects of receiving PRFM have been explained to me, and I understand all the information provided. I have consulted my physician and have correctly answered all questions regarding my medical history.

I understand that studies using the Selphyl system in pregnant and breast-feeding women have not been conducted or reported and I have discussed this with my physician before receiving treatment.

I understand that the potential adverse effects of receiving PRFM may include:

         Inflammatory reactions such as redness, edema and pain in the injected area

         Swelling at the injection site

Contraindications associated with PRFM include:

         Areas of infectious skin problems

         Persons susceptible to hypertrophic scarring or autoimmune disease

         Persons that are anemic

         Persons on medication that can affect platelet function

I consent to the injection of a PRFM derived from my own blood.