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Practitioners and staff are responsible for ensuring that patients receive accurate information concerning the nature, risks and costs associated with a given procedure or treatment.

This sample consent form is provided for your convenience and should be reviewed and edited to ensure that its contents comply with your local regulatory (legal) and institutional requirements.

The form should be reviewed periodically to ensure that its contents are current.

Cryomed Australia cannot and does not recommend standard operating procedures related to the practice of medicine.

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LOTUS TREATMENTPATIENT CONSENT FORM

CLIENT INFORMATION DATE:

NAME: D.O.B.

ABOUT LOTUS GYNOLASERLOTUS GynoLaser offers safe, effective treatment for the symptoms of vaginal relaxation syndrome (VRS), vaginal atrophy (ageing) and stress urinary incontinence (light bladder leakage). These conditions can affect women of all ages, causing physical discomfort as well as emotional stress and a loss of confidence both personally and in intimate relationships.Symptoms of these conditions include: Vaginal itchiness Vaginal burning Diminished sensation during intercourse Dyspareunia (painful intercourse) Decreased sexual sensitivity for both partners Vaginal and vulval pain or discomfort Dryness and loss of lubrication Vaginal laxity (looseness) Stress incontinence Recurrent thrush

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Doctor/Practice NameAddressPhone

HOW LOTUS GYNOLASER WORKS The LOTUS GynoLaser uses proven CO2 laser technology, which has been

extensively used in highly delicate surgical procedures for over 50 years. The developments incorporated in the LOTUS GynoLaser make it one of the most advanced lasers used in modern medicine.

LOTUS treatment enhances the vaginal mucosa and restores a healthy, youthful structure. It activates the fibroblasts of the mucosa and this helps promote collagen synthesis. This results in increased water content, increased small blood vessel formation (capillaries), and better transportation of nutrients. The vaginal mucosa are revitalised and rehydrated.

REQUIRED NUMBER OF TREATMENTSSome people see a result after one LOTUS treatment, but typically two or three treatments every consecutive month are required, then as required if/when symptoms return.

WHAT TO EXPECT AFTER LOTUS TREATMENT The LOTUS is a non-surgical, almost pain-free, 10-minute procedure, so

there is no downtime and you can return to normal activities immediately. Results will become noticeable around 30 days after the first treatment.

If you have treatment on the vulval area, you may experience a slight burning sensation. You may also notice increased vaginal secretions during the first couple of days post-treatment.

Your doctor will advise you when you can return to normal sexual activity: usually in around two weeks.

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CONSENT FOR LOTUS GYNOLASER TREATMENTI authorise Dr _____________________ to perform fractional CO2 laser (LOTUS Gynolaser) treatment on my vulvo-vaginal area. I acknowledge that I have read and understood all of the information written above, as well as that contained within the information sheet. I also acknowledge that the doctor has provided me with information concerning: the procedure the likely results available alternative treatments, including the option of no treatment at

all the possible risks the post-treatment courseI also understand that not adhering to the post-treatment care instructions provided to me by the Doctor may decrease the likelihood of a positive outcome.

I therefore agree to undergo the proposed laser treatment.

PATIENT’S NAME:

PATIENT’S SIGNATURE: DATE:

DOCTOR’S NAME:

DOCTOR’S SIGNATURE: DATE:

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