I have answered all the questions on this form truthfully and disclosed my medical history to the best of my kowledge.

Botox or Dysport therapy for wrinkles is an injection treatment designed to reduce facial expression lines. They are both approved by the FDA for the treatment of wrinkles in the glabellar area. When this therapy is performed, small amounts of toxin are injected into the facial muscles responsible for movement associated with lines and wrinkles. This injection weakens or paralyzes the muscles, thus reducing the associated lines and wrinkles. The most common areas for this therapy are the lines between the eyes, forehead wrinkles, crows’ feet and on occasion around the mouth. This therapy is temporary, meaning it has to be repeated on a regular basis to remain effective. The weakening effect gradually begins anywhere from 24 hours to 3 days and is sometimes not complete for two weeks. During this period, you may notice asymmetry, or an evenness, within treated areas. This asymmetry will usually correct itself as the toxin takes effect. For maximal result it is recommended that you maintain an upright posture for at least four hours. During this time is also recommended that the treated area not be rubbed vigorously or massaged. You may wish to actively move by expression the treated areas during this time, as this may help to increase the response of the targeted muscles.

There are no known permanent side effects. There are however, several possible side effects that are temporary which include: 

Bruising: Occurs at or near the injection site. This effect clears within 7 to 10 days. No treatment is necessary.

Headache: Related to the actual injections, it is usually mild and transient, lasting less than 24 hours. May be relieved with Tylenol.

Asymmetry: As described above, if present, will be noticed in the first two weeks of therapy. May be corrected with “touch-up” injections if necessary. There is a fee for touch up injections.

Numbness: A change in sensation noticed by some patients in the treated areas, better described as “dullness”, it is usually only noticed for a few days after treatment.

Eyebrow or eyelid ptosis (drooping) or diplopia (double vision): Seen 1-2% of patients receiving this therapy, is temporary, lasting weeks and usually mild.

Also for reasons not fully understood, some patients may be less sensitive or “resistant” to the effects of the toxins. Very deep creases may not be completely resolved with treatment.

If you are pregnant or nursing, these treatments are not recommended.

Because this therapy for wrinkles is considered a cosmetic procedure, insurance does not pay for treatment. Payment at the time of service is requested for all patients.

Botox and Dysport range in price based on the number of units used. In general Dysport is slightly less expensive than Botox. Prices start at approximately $350 for the glabellar area (the small area between the brows where we frown). Each additional area is approximately an extra $150; so for all three areas (typically frown, forehead and crows feet) it will range from $550-750

By signing below, I agree that I have read and understand the above information, and that my questions have been fully answered to my satisfaction. I understand that the practice of medicine and surgery is not an exact science and that results are not guaranteed. I agreed to be personally and fully responsible for all fees. 

Dermal Fillers

Dermal fillers are used for the treatment of facial creases, wrinkles, folds,contour defects, depression scars, facial lipoatrophy (loss of fat) and enhancement purposes. These treatments involve multiple injections of filler into or below the skin to fill wrinkles and restore volume. The effects of dermal fillers are temporary and no guarantees can be made regarding how long correction will last in a specific patient

Alternatives to temporary fillers include, but are not limited to: permanent dermal fillers, laser resurfacing and skin tightening, surgical face-lift, or no treatment at all.

Possible risks, side-effects and complications with dermal fillers include, but are not limited to:

Bruising, redness and swelling.

Visible raised areas, or bumpiness at/around treated site.

Asymmetry, overcorrection or undercorrection.

Unpredictable persistence of filler, either shorter or longer than expected.

Prolonged discoloration of the skin such as brown, grayish, bluish or reddish coloration.

Filler may be extruded from the skin in rare cases.

Prolonged or severe swellingnInfection.

Rarely granulomas or firm nodules may form.

Benign tumor formation (keratoacanthomas).

Allergic reaction with itchiness, redness, and in extremely rare cases generalized allergic response such as whole body swelling, respiratory problems and shock.

Scarring is extremely rare.

Skin breakdown or ulceration.

Blindness.

A remote and rare risk is that of filler injection into a blood vessel (blood vessel occlusion) or overfilling tissue that can block blood flow to the treated area or to distant areas, causing tissue damage or tissue death (necrosis) which can be seen as skin breakdown or ulceration. Blood vessel occlusion near the eye.

The administration of anesthetics may be necessary or advisable in association with  dermal filler treatments to reduce pain. This includes, but is not limited to: local anesthetic injections with lidocaine 1-2%with or without epinephrine: and/or topical anesthetics such as benzocaine/lidocaine/tetracaine; and/or topical oral benzocaine preparations.Complications of these anesthetics include, but are not limited to: skin irritation (itching or redness), lightheadedness, rapid heart rate, visual disturbance, tongue numbness, and seizure.

Photographs taken shall be part of the medical record and used for documentation of response to treatment.

Pricing is dertermined by the type of product used and ranges from about $700 to $850 per 1cc syringe used.  Your provider will estimate how many syringes may be needed to achieve desired results. 

My signature below certifies that I have fully read this consent form and understand the written information provided to me regarding the procedure. I have been adequately informed about the procedure including the potential benefits, risks, limitations and alternate treatments, and I have had all questions and concerns answered to my satisfaction.

 

BBL Consent:

I understand that the Sciton BBL is intended for benign vascular and pigmented lesions, and/or permanent hair reduction and that clinical results may vary in different skin types.  I understand that there is a possibility of rare side effects such as scarring and permanent discoloration as well as short term effects such as reddening, mild burning, temporary bruising and temporary discoloration of the skin.  These effects have all been fully explained to me.

Based on the experience of other physicians we have found that those people who tend to sunburn rather than tan, usually obtain good results on the first and subsequent visits.  On the other hand, those who tan more easily or have a darker skin type, tend to have more variation in their results.  Some patients in this category will experience partial results and some will experience no improvement at all.

I understand that the treatment by the Sciton BBL system involves payment.  Price for BBL starts at $495 per treatment for the face, and there is an additional fee for each additional body area.

I also understand that there are other options for treatment, such as topical creams and other laser options and these other options has been explained to me.

SCULPTRA

Sculptra is a sterile suspension of Poly-L-Lactic acid, which is a biocompatible (does not harm the body), synthetic polymer from the alpha-hydroxy acid family (fruit acids Poly-L-Lactic acid has been used medically for many years in dissolvable stitches. Sculptra is designed to help correct skin depression, such as creases, wrinkles, folds, scars,  skin aging, and facial lip-atrophy (loss of fat

Sculptra has been used since 1999 in more than 150,000 patients in more than 30 countries, primarily for cosmetic use. Yo u r D - L u x Medspa team member has informed you that, depending on the area and condition treated, the volume of Sculptra used in the injection, the effect of a treatment with Sculptra may last from 1 to 2 years, but that in some cases the duration of the effect can be shorter or longer. Most areas of treatment will require multiple sessions of 2 vials at each session at 6-12 week intervals, for optimal correction. Because individual response to Sculptra may vary, the exact number of treatments sessions required cannot be predicted with complete accuracy. Additionally, in order to maintain the desired degree of correction, intermittent “touch-up” treatments may be needed.

You have been informed on some of the features, benefits, and possible risks involved with Sculptra and have had your questions answered to your satisfaction. Some of the possible risks include:

1. After the injection(s), some common injection-related reactions probably will occur. These may include swelling, redness, pain, itching, discoloration and tenderness at the injection site. These typically resolve spontaneously, usually within 1 to 15 days after injection.

2. Because Sculptra is injected in a solution containing water, there will be an initial swelling (edema) that will be noticeable for at least several hours and perhaps as long as several days. This effect is temporary and does not affect the long-term tissue response.

3. Induration, or a feeling of fullness or thickness, can be felt in the injection areas. This is a normal response of the treated tissue to the process of inflammation and new collagen formation. Simply massaging the treated areas gently 5 times per day for 5 minutes after the injection can help minimize induration.

4. One possible delayed side effect is small bumps under the skin, termed micro-nodules, which may be non- visible or visible and may be felt in the areas of treatment. Usually these bumps may only be felt when pressing on the skin. Micro-nodules tend to occur within the first 3 to 12 months after the treatment. They usually do not require treatment and usually do not have any symptoms.

5. Visible bumps may occur in rare instances and they be associated with redness, tenderness, skin discoloration or textural alteration. These bumps, which may be termed granuloma, may or may not require treatment, including, but not limited to, injection, freezing or excision.

6. Other rarely reported adverse events include: injection site abscess, allergic reaction, skin hypertrophy (exaggerated reduction of collagen and tissue elasticity) and/or atrophy (reduction of collagen and tissue elasticity), malaise, fatigue and swelling (edema

7. The use of anti-inflammatory drugs, anti-clotting agents or aspirin might cause bleeding or increased bruising at the injection site.

8.  Pricing for a Sculptra starts at $1800 per session and includes 2 vials of Sculptra. 

I understand this is an elective procedure and I hereby voluntarily consent to treatment for facial rejuvenation, establish proper smile lines, and replacing facial volume. The procedure has been fully explained to me. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure and I understand that no guarantees are implied as to the outcome of the procedure. I also certify that if I have any changes in my medical history I will notify D-Lux Medspa immediately. I also state that I read and write in English. 

HIPAA Compliance Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health

Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

·      Protected health information may be disclosed or used for treatment, payment, or healthcare operations.

·       The practice reserves the right to change the privacy policy as allowed by law.

·      The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.

·      The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.

·       The practice may condition receipt of treatment upon execution of this consent.