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O-Shot Safety & Consent Form
Nothing contained on this website is intended to represent a promise, guarantee or warranty that any patient who undergoes the O-Shot® (Orgasm Shot®) procedure will achieve a particular result. Individual results do vary, and no responsibility is assumed for failure to achieve a desired result. No promise or representation, guarantee, or warranty regarding its use, benefit, or other quality is made. No representations that the use of this procedure is approved by the FDA or any other agency of the federal or state government is made.
The O-Shot® (Orgasm Shot®) procedure is not an FDA approved procedure; the FDA does not govern procedures (which the O-Shot® is), nor does the FDA govern PRP (which is a “minimally manipulated” isolate of the person’s own blood), just as the FDA does not govern a person’s urine, saliva, or skin.
Multiple studies have shown that PRP can be used to improve blood flow, increase collagen production, regenerate nerve, and remodel scars into more normal tissue (click to read)<–. The vast majority of the studies show that PRP is safe and rarely causes complications, but the results in any one particular patient cannot be predicted. Any sign of ill effects should be reported to your provider of the procedure.
To view scientific articles on the conditions where PRP is injected into the vagina, peri-urethra, and labial areals, click here<–
It is important that every patient understands the risk, complications, and alternatives; so, here is the actual consent form; patients should read it, understand it and sign it before the procedure.
Consent for Orgasm Shot® / O Shot® Procedure Vaginal Submucosal/Suburethral, Clitoral, and/or Labial Injection of Platelet Rich Plasma And Administration of Anesthesia
A. CONSENT FOR ORGASM SHOT®/O SHOT® 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 Orgasm Shot®/O Shot® procedure will achieve a particular result. I fully understand that individual results do vary and that
Belle Visage Medical Aesthetics 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 Belle Visage Medical Aesthetics to treat my condition, including performing further diagnosis and the procedures described below, and taking any needed photographs.
2. I understand the proposed Orgasm Shot®/O Shot® procedure(s) to be: a procedure for vaginal, labial, and clitoral rejuvenation, using blood-derived growth factors (platelet-rich fibrin matrix (PRFM), and platelet-rich plasma (PRP) injections.
3. I understand the risks associated with the proposed procedure(s) to be:
- Bleeding
- Infections
- Urinary retention
- No effect at all
- Allergic reactions
- 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
- Urethral injury (tube you urinate through)
- Urinary retention
- Hematuria (blood in urine)
- UTI (Urinary Tract Infection)
- Urinary Urgency (feel like you always have to urinate)
- Urinary Frequency
- Increased/worsening nocturia (waking up several times at night to urinate)
- Change in urinary stream
- Urethral vaginal fistula (hole between urethra and vagina)
- Vesico-vaginal fistula (hole between bladder and vagina)
- Dyspareunia (Painful intercourse)
- Need for subsequent surgery
- Alteration of vaginal sensations
- Scar formation (vaginal)
- Urethral stricture (abnormal narrowing of the urethra)
- Local tissue infarction and necrosis
- Yeast infections
- Vaginal Discharges
- Spotting between periods
- Bladder Pains
- Overactive Bladder (OAB)
- Bladder Fullness
- Exposed Material
- Pelvic Pains
- Pelvic Heaviness
- Erosions
- Fatigue
- Damage to nearby organs including bladder, urethra and ureters
- Alteration of bladder dynamics
- Post-operative pain
- Prolonged pain
- Intractable pain
- Alteration of the female sexual response cycle
- Failed procedure
- Varied results
- Psychological alterations
- Relationship problems
- Sex life alteration
- Decreased sexual function
- Possible hospitalization for treatment of complications
- Lidocaine toxicity
- Anesthesia reaction
- Embolism
- Depression
- Reactions to medications
- including anaphylaxis
- Nerve damage
- Permanent numbness
- Slow healing
- Swelling
- Sexual dysfunction
- Allergy
- Nodule formation
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 from lidocaine.
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.
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