INFORMED CONSENT FOR BOTULINUM TOXIN and/or DERMAL FILLER TREATMENT
THE TREATMENT OF BOTULINUM TOXIN
Botulinum toxin, Botox®, Dysport®, Xeomin® are neurotoxins produced by the bacterium Clostridium A. Botulinum toxin can relax the muscles on areas of the face and neck which cause wrinkles associated with facial expressions or facial pain. Treatment with botulinum toxin can cause your facial expression lines or wrinkles to be less noticeable or essentially disappear. Areas most frequently treated are: a) glabellar area of frown lines, located between the eyes; b) crow's feet (lateral areas of the eyes); c) forehead wrinkles; d) radial lip lines (smokers lines); e) head and neck muscles. Botox is diluted to a very controlled solution and when injected into the muscles with a very thin needle, it is almost painless. Patients may feel a slight burning sensation while the solution is being injected. The procedure takes about 15-20 minutes and the results can last up to 3-4 months. With repeated treatments, the results are generally consistent.
THE TREATMENT OF DERMAL FILLER
The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives of the procedure named above. This material serves a supplement to the discussion you have with your doctor/healthcare provider. It is important that you fully understand this information, so please read this document thoroughly. If have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing the consent form.
Treatment with dermal fillers (such as Juvéderm Ultra and Ultra Plus, Restylane, Belotero, Radiesse, Voluma and others can smooth out facial folds and wrinkles, add volume to the lips, and contour facial features that have lost their volume and fullness due to aging, sun exposure, illness, etc. Facial rejuvenation can be carried out with minimal complications. These dermal fillers are injected under the skin with a very fine needle. This produces natural appearing volume under wrinkles and folds which are lifted up and smoothed out. The results can often be seen immediately.
RISKS AND COMPLICATIONS
Before undergoing this procedure, understanding the risks is essential. No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalization, and/or extend outpatient therapy to permit adequate treatment. It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure and in this specific instance such risks include but are not limited to: 1) Post treatment discomfort, swelling, redness, bruising, and discoloration; 2) Post treatment infection associated with any transcutaneous injection; 3) Allergic reaction; 4) Reactivation of herpes (cold sores); 5) Lumpiness, visible yellow or white patches; 6) Granuloma formation; 7) Localized necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occurs; 8) Double vision: 9) A weakened tear duct; 10) Transient headache: 11) Flu-like symptoms may occur; 12) Occasional numbness of the forehead lasting up to 2-3 weeks; 13) Minor temporary droop of eyelid(s) in approximately 2% of injections, this usually lasts 2-3 weeks
PREGNANCY, ALLERGIES & NEUROLOGIC DISEASE
I am not aware that I am pregnant, and I am not trying to get pregnant, I am not lactating (nursing). I do not have any significant neurologic disease including but not limited to myasthenia gravis, multiple sclerosis, lambert-eaton syndrome, amyotrophic lateral sclerosis (ALS), and Parkinson’s. I do not have any allergies to the toxin ingredients, to human albumin or eggs.
Alternative procedures and options that I have volunteered for have been fully explained to me.
RIGHT TO DISCONTINUE TREATMENT
I understand that I have the right to discontinue treatment at any time.
RESULTS FOR BOTULINUM TOXIN
I am aware that when small amounts of purified botulinum toxin are injected into a muscle it causes weakness or paralysis of that muscle. Results may appear as soon as 2-10 days and usually lasts up to 3-4 months but can be shorter or longer. In a very small number of individuals, the injection does not work as satisfactorily or for as long as usual and there are some individuals who do not respond at all. I understand that I will not be able to use the muscles injected as before while the injection is effective but that this will lessen after a period of months at which time additional treatment may be required to maintain results. I understand that I must stay in the erect posture and that I must not manipulate the area(s) of the injections for the 4 hours post-injection period.
I understand this is an elective procedure and I hereby voluntarily consent to treatment with botulinum toxin injections for facial dynamic wrinkles, TMJ dysfunction, bruxism, and types of orofacial pain, including headaches and migraines. The procedure has been fully explained to me. I also understand that any treatment performed is between me and the doctor/healthcare provider who is treating me and I will direct all post-operative questions or concerns to the treating clinician. 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 to the outcome of the procedure. I also certify that if I have any changes in my medical history, I will notify the doctor/healthcare professional who treated me immediately. I also state that I read and write in English.
RESULTS FOR DERMAL FILLER
Dermal fillers have been shown to be safe and effective when compared to collagen skin implants and related products to fill in wrinkles, lines and folds in the skin on the face. Its effect can last up to 6 months. Most patients are pleased with the results of dermal fillers use. However, like any esthetic procedure, there is no guarantee that you will not require additional treatments to achieve the results you seek. The dermal filler procedure is temporary and additional treatments will be required periodically, generally within 4-6 months and up to one year, involving additional injections for the effect to continue. I am aware that follow-up treatments will be needed to maintain the full effects. I am aware the duration of treatment is dependent on may factors but not limited to: age, sex, tissue conditions, my general health and life style conditions, and sun exposure. The correction, depending on these factors, may last up to 1 year and in some cases shorter and some longer. I have been instructed in and understand the post-treatment instructions.
I understand this is an elective procedure and I hereby voluntarily consent to treatment with dermal fillers for facial rejuvenation, lip enhancement, establish proper lip and smile lines, and replacing facial volume. The procedure has been fully explained to me. I also understand that any treatment performed is between me and the doctor/ healthcare provider who is treating me and I will direct all post-operative questions or concerns to the treating clinician. I have read the above and 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 the doctor/healthcare professional who treated me immediately. I also state that I read and write in English.
I understand that results are not guaranteed, and I may not see the complete desired effect. Refunds will only be given if and only at the clinic’s discretion. i.e., if an error was made by the injector.