PDO Thread Lift Consent Form

Patient Information

Full Name

Date of Birth

Phone Number

Email Address

Emergency Contact Name & Number

Treatment Details

Treatment Area(s)

Thread Type (tick all that apply):

Mono Threads (smooth) - for skin tightening and collagen stimulation

Cog/Barbed Threads - for lifting and repositioning

Screw Threads - for volume restoration

Number of Threads

Product Brand / Batch Number

IMPORTANT: Thread lifts are an invasive procedure

This treatment involves inserting absorbable threads beneath the skin. While PDO is biocompatible and dissolves naturally over 6-9 months, complications can occur. Please ensure you understand all risks before proceeding.

Contraindications - Please confirm you do NOT have any of the following:

Pregnancy or breastfeeding

Active skin infection or inflammation in treatment area

Autoimmune or connective tissue disorders

Blood clotting disorders or anticoagulant medication

History of keloid or hypertrophic scarring

Allergy to PDO (polydioxanone) material

Active cancer or immunosuppression

Unrealistic expectations about results

Risks and Potential Complications

I understand that the following may occur:

Expected: Swelling and bruising (may last 1-2 weeks)

Expected: Tenderness and discomfort at entry points

Common: Temporary puckering or dimpling of skin (usually resolves)

Common: Asymmetry (may require adjustment)

Uncommon: Visible or palpable threads under skin

Uncommon: Thread migration

Uncommon: Infection requiring antibiotics

Rare: Thread extrusion (thread poking through skin)

Rare: Nerve damage causing numbness or weakness

Rare: Granuloma or inflammatory reaction

Rare: Permanent scarring

Patient Acknowledgements

I have read and understood this consent form and agree to proceed with treatment.

Patient Signature

Date

Practitioner Signature

Practitioner Name (Print)