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.