Stem Cell Treatment Consent Form

REGENCELL STEM CELL TREATMENTS

Op. Dr. Can Çobanoğlu

Stem Cell treatment consent form (Stem cell transplantation)

Stem cell treatment is an intervention strategy in which new cells are administrated into the damaged area with the purpose of treating the disease or injury.

Your doctor offered you stem cell treatment for the treatment of the disease or injury you are diagnosed with. Front clinical research showed that stem cell transplantation might be an efficient method. Although there is no treatment with no risk in medicine, side effects of stem cell treatment are very rare and they are slight fever, stimulation after transplantation or headache, which usually spontaneously fade away in 24-48 hours.

However, these findings may be seen during stem cell transplantation or after which are not limited to the ones below, depending on personal differences:

-          Stem cell transplantation may heal the person’s disease, injury or condition in certain amount. However, potential healing effects may change in each person, according to personal differences.

-          As told above, in approximately %1 of the patients, slight fever, headache or post transplantation stimulation may develop and this condition usually get better in 24-48 hours spontaneously.

-          Stem cells may rarely induce an anaphylactic response.

-          It is not possible to eliminate the possibility of developing an unknown syndrome or reaction due to this procedure which is still in trial phases.

In case of acute side effect occurrence, proper emergent treatment will be applied right away. It is very important that patient or legal representative must know the benefit and risks of this potential treatment option. If you agree to what we told above and want this stem cell transplantation treatment to be done, please sign below.

I have read and completely understood all the information above.

PATIENT: ……………………………………….      Date ………../……/………   Attester: ……………………… (Signature)

For patients who cannot give consent, legal representative on patient’s behalf:

………………………………………………….. Attester: …………………………..(signature) Date ………../……/………