This elective procedure may help improve sexual responsiveness for some women for several months. The procedure starts with the patient identifying their sensitive “Gräfenberg” spot on the anterior/inner/upper side of the vagina. This area of sensitive tissue, up behind the pubic bone can be temporarily numbed with local and/or injectable anesthesia. Filler is carefully injected to enlarge, thicken and firm up this tissue. This may enhance stimulation to this area during sexual relations. The procedure is temporary, but may be repeated periodically as desired.
This document is NOT intended to promise, guarantee, or warranty that any patient who undergoes a “Z-Shot”® will achieve a particular result. Individual results do vary and no responsibility is assumed for failure to achieve a desired result. The use of various filler materials (hyaluronic gels, particulate fascia, calcium hydroxi-appetite and methyl cellulose) in this procedure is an “off label” use. No representation that the use of these products and this procedure is approved by the FDA or any other agency of the federal or state government is made.
CONSENT FOR PROCEDURE:
I have supplied and received information about my condition, the proposed treatment, alternatives and related risks. I have received an explanation of any unfamiliar terms and have been offered the opportunity to ask questions. I give my informed and voluntary consent to the procedures and the other matters shown below. I also consent to the performance of any additional procedures determined in the course of the procedure to be in my best interests and where delay might impair my health.
The proposed procedure involves injection of a non-permanent filler material into the sub-mucosal (skin lining) membrane of the vagina, near the urethra, in order to attempt to enhance sexual stimulation.
The risks associated with the proposed procedure(s) include, but are not limited to: Bleeding, Infection, Urinary Retention, Accelerated filler re-absorption, No effect/Failed procedure, Allergic reaction, Awareness of the injection site, Alteration of vaginal sensation, Altered function, Hematoma, Ulceration, Hematuria, Urinary tract infection, Change in urinary function, Painful intercourse, Post-operative pain, Anesthesia reaction; Nerve damage, Migration of material, Nodule formation, Hyper-arousal syndrome.
There may be other risks or complications or serious injury from both known and unknown causes. The practice of medicine and surgery is not an exact science and I acknowledge that no guarantees are made concerning the risks, procedure, or outcome.
I further understand that I may choose not to have this procedure.
CONSENT FOR ANESTHESIA:
Local and topical anesthetics are required to perform the procedure more comfortably. They are administered by, and under the orders of Dr, Zimmerman/Dr. Lee. The risks of any anesthesia include: local discomfort, swelling, bruising, allergic reactions to medications, seizures and death.
I am 18 years of age or older and authorized and/or able to consent to this procedure and the use of anesthetics. I understand the information on this form and give my consent for this elective procedure. All my questions have been answered to my satisfaction.