11550 Jonesbridge Rd, Suite# 6, Alpharetta GA 30022
Email: info@cosmomedspaatl.com         Tel: (678) 829-7722

The Orgasm Shot Consent Form

Though Platelet-Rich Plasma (PRP) comes from your own body and has demonstrated a low complication rate in other areas of the body, injecting PRP into vaginal structures and near the clitoris (the Orgasm Shot, abbreviated as the O-Shot) is a new procedure and so could cause some unexpected side effects or complications. At present, it is only being offered as part of a clinical trial designed to assess its effectiveness and safety.

Nothing contained in this consent form or in any other information provided to potential patients is intended to represent a promise, guarantee, or warranty that any patient who undergoes the Orgasm Shot™/O-Shot™ will achieve a particular result. Individual results vary, and no responsibility is assumed for failure to achieve a desired result.

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. Consent for Vaginal Submucosal/Suburethral, Labial, and Clitoral Injection of PRP And Administration of Anesthesia

CONSENT FOR PROCEDURE
M/br> I have received information about my condition, the proposed treatment, alternatives, and related risks. This form contains a summary of this information. I have received an explanation of any unfamiliar terms and have been offered the opportunity to ask questions. 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 during a procedure to be in my best interests and where delay might impair my health

  • I authorize Specialist to treat my condition, including performing further diagnosis and the procedures described below, and taking any needed photographs.
  • I understand the proposed procedure(s) to be vaginal submucosal/subureathral, clitoral, and labial, PRP (platelet rich plasma) injection (The Orgasm Shot™/The O Shot™).
  • I understand the risks associated with the proposed procedure(s) to be:
    Bleeding, No effect at all, Constant awareness of the G-Spot, A sensation of always being sexually aroused, Constant vaginal wetness, Mental preoccupation of the G-Spot, Alteration of the function of the G-Spot, Sexual function alteration, Hematoma or bruising, Hematuria (blood in urine), Alteration of vaginal sensations (usually with more intense pleasure), Hypersexuality (overactive sex drive), Alteration of the female sexual response cycle, Varied results and Sex life alteration.
  • 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.
  • 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 Specialist: I consent to the administration of such local anesthetics as may be considered necessary by the Specialist in charge of my care. I understand that the risks of local anesthesia include local discomfort, swelling, bruising, allergic reactions to medications, and seizures from lidocaine. WAIVER AGREEMENT THE UNDERSIGNED acknowledges that I am 18 years of age or older and the Specialist has explained the nature of all the above noted treatment of Orgasm Shot procedures including the risks and dangers inherent therein.

I HEREBY CONSENT to performing the above-noted treatment procedures on me and in consideration of their so doing; I hereby release and forever discharge Cosmo Med Spa & Salon, from all claims, demands, damages, actions or causes of action arising out of the performance of the said treatment procedures, which I, my heirs, executors, administrators, or assigns can, shall, or may have. (NO REFUND ON ANY TREATMENT.)