Purpose of the Consent:  To provide written information regarding the risks, benefits, and alternatives of the Hyaluronic Acid Filler such as Restylane®, Juvederm, & Belotero. (Non-Animal Stabilized Hyaluronic Acid), this consent is written. It is important that the patient should fully understand the treatment priorly. Before signing the consent, the patient should ask any of the questions regarding the treatment, Hyaluronic Acid Filler, and procedures to their doctor or healthcare professional. The Treatment Information: All mammals have hyaluronic acid naturally and it contains several soft tissues. This acid can also be produced synthetically. Dermal Fillers use hyaluronic acid which is a non-animal product, so the risk of animal-based disease or allergy is low. To lessen the discomfort, the injections contain a local anesthetic. For lasting effects, the treatment should continue. After injection, the body absorbs dermal fillers slowly and the length of the effect depends on the person. Risks and Side Effects: The possible side effects are listed below. However, the patients should be aware that there may be unique effects to certain people that are not known right now. Some possible occurrences  during Tissue Filler Injections: Bleeding and Swelling,  Erythema (Skin Redness), Needle Marks, Acne-Like Skin Eruptions, Skin Lumpiness, Visible Tissue Filler Material, Asymmetry, Pain. Risks of Dermal Filler Injections: Damage to Deeper Structures, Infection, Skin Necrosis, Allergic Reactions and Hypersensitivity, Scarring, Granulomas, Antibodies to Fillers, Accidental Intra-Arterial Injection, Under /Over Correction, Migration of Dermal-Fillers, Drug, and Local Anesthetic Reactions. Limitations and Alternatives:  From time to time, there are cases that the treatment could not be successful or wears off quickly. Alternatives may include; laser treatments, chemical skin peels, other skin procedures, or alternative types of tissue fillers. 

This is an informed consent document which has been prepared to help your team inform you concerning neurotoxin injections and its risks. It is important that you read this information carefully and completely. Please initial each page, indicating that you have read the page, and sign the consent for this procedure as proposed by your plastic surgeon and agreed upon by you.

 

MicroNeedling Patient Consent:

Description of the Procedure: 

The SKINPEN skin needling system treatment allows for controlled induction of the skin’s self-repair mechanism by creating micro “injuries” in the skin which triggers new collagen synthesis. The result is smoother, firmer and younger looking skin. Skin needling procedures are performed in a safe and precise manner with the use of the sterile SKINPEN skin needling system or dermal roller treatment. The procedure is normally completed within 30-60 minutes depending on the required treatment and anatomical site. 

Side Effects: 

After the procedure, the skin will be red and flushed in appearance in a similar way to moderate sunburn. You may also experience skin tightness and mild sensitivity to touch on the area being treated. The skin’s redness will diminish greatly after a few hours following the treatment and within the next 24 hours the skin will be generally calmed. After 3 days the skin will return to a normal or near normal appearance. 

Contraindications: 

Keloid scars; history of eczema, psoriasis and other chronic conditions; history of actinic (solar) keratosis; history of Herpes Simplex infections; history of diabetes; presence of raised moles, warts on targeted area. Other medical at risk conditions based upon your medical history may also contraindicate yourself from receiving treatment.

Absolute contraindications include; scleroderma, collagen vascular diseases or cardiac abnormalities; blood clotting problems; active bacterial or fungal infection; immuno-suppression; scars less than 6 months old. Not recommended for women who are pregnant or nursing. 

Patient Consent: 

I understand that results will vary between individuals. I understand that although I may see a change after my first treatment; I may require a series of sessions to obtain my desired outcome. The procedure and side effects have been explained to me including alternative methods; as have the advantages and disadvantages. I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and that, therefore, there can be no guarantee as expressed or implied either as to the success or other result of the treatment. I am aware that the SKINPEN skin needling system is not permanent as natural degradation will occur over time. I state that I have read (or it has been read to me) and I understand this consent and I understand the information contained in it.  I have had the opportunity to ask any questions about the treatment including risks or alternatives and acknowledge that all my questions about the procedure have been answered in a satisfactory manner.  THIS CONSENT FORM IS VALID UNTIL ALL OR PART IS REVOKED BY ME IN WRITING. 

 

Platelet Rich Fibrin (PRF) Informed Consent:

 

After careful examination of my condition, my provider has recommended the use of Platelet Rich Fibrin (PRF) to enhance aesthetic results.  PRF is a component of my own blood that contains growth factors. These growth factors are known to stimulate soft tissue healing. I understand that PRF is processed from my own blood and is therefore safe from disease transmission.  

I will have several vials of my own blood drawn. My blood will be placed in a centrifuge to concentrate the platelets. This will activate the platelets (make them release their growth factors).

I understand that all blood drawing materials and needles, all the centrifuge processing containers and calcium chloride containers, and mixing/activating syringes are single use and are disposed of in medical waste containers after each patient.  Each PRF procedure uses its own sterile materials and supplies. 

 

Risks and Complications of the blood draw for the PRF include but are not limited to: Pain at the draw entry, bruising, lightheadedness, inflammation of the vein and rare risk of infection.

Contraindications: There are very few contraindications, however, patients with the following conditions are not candidates: acute and chronic infections, cancer, chemotherapy treatments, severe metabolic and systemic disorders, abnormal platelet function (blood disorders, i.e. hemodynamic instability, hypofibrinogenemia, critical thrombocytopenia), chronic liver pathology, anti-coagulation therapy, underlying sepsis and systemic use of corticosteroids within two weeks of the procedure.

Photographs: I authorize the taking of clinical photographs and their use for scientific and educational publications and presentations. I understand my identity will be protected.

Post-Treatment Instructions: Do NOT touch, press, rub, or manipulate the treated area (s) for at least 8 hours after your treatment. Avoid Aspirin, Motrin, Ibuprofen, Aleve (all non-steroidal and steroidal anti-inflammatory agents), Gingko Biloba, Garlic, Flax Oil, Cod liver Oil, Vitamin A, Vitamin E, or any other essential fatty acids at least 3 days-1 week prior to and after your treatment. Remember, we are creating inflammation. If you experience discomfort or pain you may take Tylenol or other Acetaminophen products.  Avoid vigorous exercise, alcohol, caffeine, and cigarettes for 3 days after your treatment.

Please note that smokers do not heal well and problems recur earlier and results may take longer.  I understand that I should call the office if I have any questions or concerns regarding my treatment or post-operative care.  

 

Consent: My consent and authorization for this procedure is strictly voluntary. By signing this informed consent form, I agree that I have read this informed consent and certify I understand it’s contents in full. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement.  I agree to adhere to all safety precautions and instructions after the treatment.  I have been instructed in and understand post treatment instructions and have been given a written copy of them. I understand that medicine is not an exact science and acknowledge that no guarantee has been given or implied by anyone as to the results that may be obtained by this treatment.  I also understand this procedure may not be covered by insurance and that payment is my responsibility.  Any expenses which may be incurred for medical care I elect to receive outside of this office, such as, but not limited to dissatisfaction of my treatment outcome will be my sole financial responsibility. Payment in full for all treatments is required at the time of service and is non-refundable.

I have been fully informed about the use of PRF, the procedure(s) to be utilized for development, the risks, benefits and alternatives.  I have had an opportunity to ask questions and to discuss any concerns with my provider.  After thorough deliberation, I hereby fully consent to the PRF process.

 

For PEELS ONLY: 

 

Prior to receiving treatment I have communicated with the Practitioner about any conditions or medications that may contraindicate this procedure.
I understand that there may be some degree of discomfort such as burning, stinging, redness, heat, or tightness during and a week after the procedure.
I understand that there is no guarantee of the final results of the peel. Occasionally hyperpigmentation may develop which may persist for a week or months after the peel.
I understand although complications are very rare, sometimes they may occur. In the event of any complications, I will immediately contact the Physician/Clinician who performed the treatment. I understand if I have any acne condition in the skin, the peel may bring out oils and bacteria from below the surface and can cause an actual breakout. I understand that maintenance of VI Peel® treatments are necessary to maintain results as well as the recommended VI Derm® skin care regimen and SPF 50+.
I understand the extended direct sun exposure including tanning beds are strictly prohibited before and after receiving the VI Peel®.
I understand no activities involving excessive sweating can be done for 72-96 hours (exercise, sauna, hot tub, steam room, and that overheating may cause me to develop blisters or cause hyperpigmentation to worsen.)
I understand that I must protect my skin with VI Derm® SPF 50+ and avoid sun exposure during the 7 day exfoliation process.
I understand that this is an elective cosmetic procedure.
I understand that no other chemical peels, facial machine brushes, or medical device (laser, IPL, etc) treatments may be performed on my skin until my physician/clinician releases me to do so.

The VI Peel contains a synergistic blend of powerful ingredients suitable for all skin types. VI Peel will improve the tone, texture and clarity of the skin; reduce age spots, improve hyperpigmentation (including melasma), soften lines and wrinkles; clear acne skin conditions; reduce or eliminate acne scars; and stimulate the production of collagen, for firmer, more youthful skin.

Contraindications:
• Patients who are pregnant or who are breastfeeding
• Patients who have an aspirin, hydroquinone, or phenol allergy
• Patients who have used oral isotretinoin (Accutane) within the past 6 months
• Patients who have active cold sores, warts, open wounds, or history of herpes simplex
• Patients who are undergoing chemotherapy and or radiation therapy within 6 months
• Patients with a history of an autoimmune (i.e. Lupus) or liver disease/disorder, as well as, any condition that may weaken their immune system

The nature and purpose of the treatment have been explained to me. I have read and understand this agreement in its entirety. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment.

 

I understand that my aftercare of the peel remains as the following: 

Avoid sun exposure, avoid sweating and avoid heat.

Each morning apply the Post Peel Protectant and SPF 50+ Sunscreen and apply as needed throughout the day. Continue use for the 7-Day peeling process.

(Typically, peeling begins on the third day, starting in the peri-oral area then peeling outward. The forehead and neck will be the last areas to peel.)

 

While the skin is exfoliating avoid pulling, picking, rubbing and any premature removal of skin. This could lead to significant irritation and possible hyperpigmentation. Never force or peel the skin off in sheets.
When peeling make sure to keep your body hydrated and your skin moisturized.

 

If you are excessively dry or irritated when peeling, add a light layer of Aquaphor to provide a protective barrier.

 

Refrain from intense working out for a few days after peel application. Peels can be scheduled every 6 weeks for best results. 

 

It is recommended to wait for a minimum of 2 weeks before any treatment that creates exfoliation of the skin. (Includes facials, extractions, waxing, and threading). 

 

It is advised to wait 1-2 weeks after injections before getting a chemical peel, and please wait 24 hours after a chemical peel before getting botox. 

 

In the case my filler must dissolved, I consent to the following: 

 

HYLENEX® recombinant is a purified preparation of the enzyme recombinant human hyaluronidase produced by genetically engineered Chinese Hamster Ovary (CHO) cells containing a DNA plasmid encoding for a soluble fragment of human hyaluronidase (PH20). It is used to increase the absorption and dispersion of injected drugs or to disrupt the structure of certain organs.   It is used off label to help decrease excess hyaluronic acid fillers or the Tyndall effect (blue-ish tint) which can occur if hyaluronic acid fillers are injected too superficially. I understand that this medication can be unpredictable and spread, and may dissolve all the filler that was injected. 

 

RISKS OF INJECTION 

Every procedure involves a certain amount of risk and it is important that you understand these risks and the possible complications associated with them. In addition, every procedure has limitations. An individual’s choice to undergo this procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience the following, you should discuss each of them with your physician to make sure you understand the risks, potential complications, limitations, and consequences.  Additional information concerning Hylenex® may be obtained from the package-insert supplied by Halozyme Therapeutics, Inc.   

Bleeding and Bruising: It is possible, though unusual, to have a bleeding episode from an injection.  Bruising in soft tissues may occur. Should you develop post-injection bleeding, it may require emergency treatment or surgery. Aspirin, anti-inflammatory medications, platelet inhibitors, anticoagulants, Vitamin E, ginkgo biloba and other “herbs / homeopathic remedies” may contribute to a greater risk of a bleeding problem. Do not take any of these for 7 days before or after injections.

Itching/Swelling/Pain/Redness: Itching and swelling is a normal occurrence following the injections. It decreases after a few days. If swelling is slow to resolve, medical treatment may be necessary. Discomfort associated with injections is normal and usually of short duration. Redness  in the skin occurs after injections. It can be present for a few days after the procedure.

Infection: Although infection is unusual, bacterial, fungal, and viral infections can occur. Herpes simplex virus infections around the mouth can occur following treatment. This applies to both individuals with a past history of Herpes simplex virus infections and individuals with no known history of Herpes simplex virus infections in the mouth area. Specific medications must be prescribed and taken both prior to and following the treatment procedure in order to suppress an infection from this virus. Should any type of skin infection occur, additional treatment including antibiotics may be necessary.  Hylenex®  should not be injected into or around an infected or acutely inflamed area because of the danger of spreading a localized infection.

Pregnancy and Nursing Mothers: It is unknown if Hylenex® can cause harm to the fetus. If you become pregnant while taking Hylenex®, discuss with your doctor the benefits and risks of using Hylenex® during pregnancy. Hylenex® does not cause problems during labor, but it is unknown if it can cause harm to the fetus during labor. It is unknown if Hylenex® is excreted in breast milk.

 

Drug Interactions: Some medicines may interact with Hylenex®. Tell your health care provider if you are taking any other medicines, especially any of the following: Local anesthetics (eg, lidocaine) because risk of side effects of Hylenex®  may be increased;  Antihistamines (eg, diphenhydramine), certain hormones (eg, corticotropin, estrogens), cortisone, or salicylates (eg, aspirin) because the effectiveness of Hylenex® may be decreased.  Tell your doctor if you are taking benzodiazepines (eg, alprazolam), furosemide, or phenytoin because effectiveness may be decreased by Hylenex®.

Allergic Reactions:  In rare cases, adverse reactions to hyaluronidase have been known. The allergic reactions are quite rare, but persons with known allergies to hyaluronidase of bovine or ovine origins should not be treated with hyaluronidase. Allergic reactions may include hives, difficulty breathing, and swelling of the face, lips, tongue, or throat. 

Unknown Risks: The long term effect of Hylenex® is unknown.  The possibility of additional risk factors or complications attributable to the use of Hylenex® may be discovered.

 
I understand that it is not uncommon for the treated area to look “over-dissolved or pruned.” This is due to the reaction of native hyaluronic acid in the skin, which is quickly repleted and hydrated.

GENERAL INFORMATION

Clostridia botulinum bacteria produce a class of chemical compounds known as “toxins”. The Neurotoxins are processed and purified to produce a sterile product suitable for specific therapeutic uses. Once the diluted toxin is injected, it produces a temporary paralysis (chemodenervation) of muscle by preventing transmission of nerve impulses to muscle. The duration of muscle paralysis generally lasts for approximately three to four months. Continuing treatments are necessary in order to maintain the effect of neurotoxins over time.

Neurotoxins have been approved to treat certain conditions involving crossed eyes (strabismus), eyelid spasm (blepharospasm), cervical dystonia (spastic muscle disorder with the neck) and motor disorders of the facial nerve(VII cranial nerve). As of April 2002, it has been FDA approved for the cosmetic treatment of forehead wrinkles caused by specific muscle groups. Other areas of the face and body such as crows feet wrinkles and neck bands may be treated in an “off-label” fashion. Neurotoxins have also been used “off-label” to treat migraine headaches, colorectal disorders, excessive perspiration disorders of the armpit and hands, and musculoskeletal pain disorders.

Neurotoxin injections are customized for every patient, depending on his or her particular needs. These can be performed in areas involving the eyelid region, forehead, and neck. Neurotoxins cannot stop the process of aging. It can, however, temporarily diminish the look of wrinkles caused by muscle groups. Neurotoxin injections may be performed as a single procedure or as an adjunct to a surgical procedure.

ALTERNATIVE TREATMENTS

Alternative forms of management include not treating the skin wrinkles by any means. Improvement of skin wrinkles may be accomplished by other treatments or alternative types of surgery such as a blepharoplasty, face or brow lift when indicated. Other forms of eyelid surgery may be needed should you have intrinsic disorders affecting the function of the eyelid such as drooping eyelids from muscle problems (eyelid ptosis) or looseness between the eyelid and eyeball (ectropion). Minor skin wrinkling may be improved through chemical skin peels, lasers, injection of filling material, or other skin treatments. Risks and potential complications are associated with alternative forms of medical or surgical treatment.

RISKS OF NEUROTOXINS

Every procedure involves a certain amount of risk and it is important that you understand these risks and the possible complications associated with them. In addition, every procedure has limitations. An individual’s choice to undergo a surgical procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience these complications, you should discuss each of them with your plastic surgeon to make sure you understand risks, potential complications, limitations, and consequences of neurotoxin injections.

Risks include but are not limited to: Incomplete Block, Bleeding and Bruising, Damage to Deeper Structures, Corneal Exposure Problems, Dry Eye Problems, Migration of Neurotoxins, Drooping Eyelid (Ptosis), Double Vision, Eyelid Ectropion, Other Eye Disorders, Blindness, Asymmetry, Pain, Allergic Reaction, Antibodies to Neurotoxins, Infection, Skin Disorders, Neuromuscular Disorders, Migraine Headache Disorders, Unsatisfactory Result, Long Term Effects, Pregnancy and/ or nursing complications, Drug Interaction, and any other Unknown Risks.

 

DISCLAIMER

Informed consent documents are used to communicate information about the proposed surgical treatment of a disease or condition along with disclosure of risks and alternative forms of treatment(s). The informed consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances.

However, informed consent documents should not be considered all-inclusive in defining other methods of care and risks encountered. Your provider may provide you with additional or different information which is based on all of the facts pertaining to your particular case and the current state of medical knowledge.

Informed consent documents are not intended to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve.

OFF-LABEL FDA USE

There are many devices, medications and injectable fillers and botulinum toxins that are approved for specific use by the FDA, but this proposed use is “Off-Label”, which is not specifically approved by the FDA. It is important that you understand this proposed use is not experimental and your physician believes it to be safe and effective.

Examples of commonly accepted “Off-Label” use of drugs or devices include the use of aspirin for prevention of heart disease, retinoids for skin care, and injection of botulinum toxin for wrinkles around the eyes. Xeomin is approved for Glabellar frown lines, Blepharospasm, and would be Off-Label for all other uses. I acknowledge that I have been informed about the Off-Label FDA status of Xeomin, and I understand it is not experimental and accept its use.

General Information

I confirm that I consent to receiving treatment using the cosmetic products that my practitioner has recommended to me.

I have been informed that the treatment is carried out by injection for the improvement of lines wrinkles and folds of the skin, for lip augmentation, and rehydration of the skin.

I have been given sufficient information to enable me to understand the use of these products for the approved indications.

I have also received information regarding contraindications to the administration of products and potential side effects.

Cosmetic products give an aesthetic result for an average of 6-18 months. This effect may be variable depending on many factors, including condition of the skin, mechanical action in the treatment area, amount of product injected and technique for injection. Lifestyle factors also effect the duration of the product. Regular touch-up treatments help to optimize the duration of the product.

Post treatment: Following treatment avoid sun exposure and saunas. Avoid manipulation of the treated area and make up, as instructed by practitioner.

General Information About Dermal Filler Injections

Some redness, swelling, hematoma, and bruising may occur following treatment. Resolution is typically spontaneous within a few days.

As with all injectable treatments, there is a minimal risk of infection, vessel occlusion, granulomas, abscess formation and hypersensitive reaction. Eye twitching may be a side effect risk with all neuromodulator products. 

Persistence of any inflammatory reaction for more than one week or the development of any other side effects must be reported to the practitioner as soon as possible.

General Information About Botulinum A Toxin Injections

Botulinum A Toxin injections in the area of the glabella muscles are made to relax these muscles temporarily or in the forehead or crows feet around the lateral area of the eyes, or other areas consulted with and approved by your practitioner.

Botulinum A Toxin injection has been FDA approved for use in the cosmetic treatment for glabella frown lines only and crows feet (Xeomin)– the wrinkles between the eyebrows.

Injection of Botulinum A Toxin into the small muscles between the brows causes those specific muscles to halt their function (be paralyzed), thereby improving the appearance of the wrinkles. I understand the goal is to decrease the wrinkles in the treated area. This paralysis is temporary, and re-injection is necessary within three to four months. It has been explained to me that other temporary and more permanent treatments are available.

The possible side effects of Botulinum A Toxin include but are not limited to:

1. Risks: I understand there is a risk of swelling, rash, headache, and local numbness, pain at the injection site, bruising, respiratory problems, and allergic reaction.

2. Infection: Infections can occur which in most cases are easily treatable but in rare cases a permanent scarring in the area can occur.

3. Most people have lightly swollen pinkish bumps where the injections went in, for a couple of hours or even several days.

4. Although many people with chronic headaches or migraines often get relief from Botulinum A Toxin, a small percent of patients get headaches following treatment with Botulinum A Toxin, for the first day. In a very small percentage of patients these headaches can persist for several days or weeks.

5. Local numbness, rash, pain at the injection site, flu like symptoms with mild fever, back pain.

6. Respiratory problems such as bronchitis or sinusitis, nausea, dizziness, and tightness or irritation of the skin.

7. Bruising is possible anytime you inject a needle into the skin. This bruising can last for several hours, days, weeks, months and in rare cases the effect of bruising could be permanent.

8. While local weakness of the injected muscles is representative of the expected pharmacological action of Botulinum A Toxin, weakness of adjacent muscles may occur as a result of the spread of the toxin.

9. Treatments: I understand more than one injection may be needed to achieve a satisfactory result.

10. Another risk when injecting Botulinum A Toxin around the eyes included corneal exposure because people may not be able to blink the eyelids as often as they should to protect the eye. This inability to protect the eye has been associated with damage to the eye as impaired vision, or double vision, which is usually temporary. This reduced blinking has been associated with corneal ulcerations. There are medications that can help lift the eyelid, however, if the drooping is too great the eye drops are not that effective. These side effects can last for several weeks or longer. This occurs in 2-5 percent of patients.

I will follow all aftercare instructions as it is crucial I do so for healing.

As Botulinum A Toxin injection is not an exact science, there might be an uneven appearance of the face with some muscles more affected by the Botulinum A Toxin than others. In most cases this uneven appearance can be corrected by injecting Botulinum A Toxin in the same or nearby muscles. However in some cases this uneven appearance can persist for several weeks or months.

This list is not meant to be inclusive of all possible risks associated with Botulinum A Toxin as there are both known and unknown side effects associated with any medication or procedure.

Botulinum A Toxin should not be administered to a pregnant or nursing woman.

Additionally, the number of units injected is an estimate of the amount of Botulinum A Toxin required to paralyze the muscles. I understand there is no guarantee of results of any treatment. I understand the regular charge applies to all subsequent treatments.

I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I further agree in the event of non-payment, to bear the cost of collection, and/or Court cost and reasonable legal fees, should this be required.

By accepting, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks. I hereby give consent to perform this and all subsequent treatments with the above understood. I hereby release the doctor, the person injecting the Botulinum A toxin and/or the dermal filler and the facility from liability associated with this procedure.

 

ADDITIONAL TREATMENT NECESSARY

There are many variable conditions in addition to risk and potential complications that may influence the long term result of neurotoxin injections. Even though risks and complications occur infrequently, the risks cited are the ones that are particularly associated with neurotoxin injections. Other complications and risks can occur but are even more uncommon. Should complications occur, additional surgery or other treatments may be necessary. The practice of medicine and surgery is not an exact science. Although good results are expected, there is no guarantee or warranty expressed or implied, on the results that may be obtained.

It is important that you read the above information carefully and have all of your questions answered before signing the consent on the next page.

Vitamin B-12 helps maintain good health and has been shown to be beneficial in helping to: reduce stress, fatigue, improve memory, and cardiovascular health, and maintain a good body weight. It can also assist the body in converting proteins, fats, and carbohydrates into energy and is necessary for healthy skin and eyes. B12 injections are better absorbed by the body once they go directly into the blood stream. Alternatives to B12 injections are oral vitamins, B12 patch, lozenges, liquid drops, and nasal spray. B12 injections common side effects include but are not limited to:

Risks: I understand there is a risk of mild diarrhea, upset stomach, nausea, a feeling of pain and a warm sensation at the site of the injection, a feeling, or a sense, of being swollen over the entire body, headache, and joint pain.

If any of these side effects become severe or troublesome I will contact my provider immediately.

I understand that although rare, vitamin injections can result in serious side effects. Although this is a relatively rare occurence, anyone taking vitamin injections should be aware of the possibility. Uncommon side effects are much more serious than the common side effects of B12 injections, and such side effects should be reported to a physician to be evaluated for seriousness.

Before starting vitamin injections I will make sure to tell my physician and not perform the injection if I am pregnant, lactating or have any of the following conditions:

• Leber's Disease

• Kidney Disease

• Liver Disease

• Folic acid deficiency

• Receiving any treatment that has an effect on bone marrow

• Taking any medication that has an effect on bone marrow

• An allergy to cobait or any other medication, vitamin, B complex dye, food or preservative, ascorbic acid USP, Thamine Hydrockloride USP, Robiflavin-5-Phosphate Sodium, Niacinamide USP poswder, Panthenol USP (DL) powder, Pyridoxine Hydrochloride, Cyanocabalamin Powder, Lidocaine Hydrochloride USP, Methionine USP (L) Powder, Inositol FCC Powder, Choline Chloride USP Powder, Sterile water, lipotropic or sulfur.

I understand that certain herbal products, vitamins, minerals, nutritional supplements, prescription and non prescription medications may result in side effects when they interact with vitamin injections. By signing below, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks. I hereby give consent to perform this and all subsequent injections with the above understood. I hereby release the the person injecting and the facility from liability associated with this procedure.

INFORMED CONSENT FOR NEUROTOXIN INJECTIONS

1. I hereby authorize injectco and such assistants as may be selected to perform the following procedure or treatment: XEOMIN NEUROMODULATOR INJECTION, DERMAL FILLERS, BIOSTIMULATORS. As the patient, I both understand and consent to XEOMIN as the preferred neurotoxin of choice which will be utlizied during my treatment due to it's reduced risk of antibody formation and double filtered purified makeup without use of extra proteins. 

2. I recognize that during the course of the procedure and medical treatment or anesthesia, unforeseen conditions may necessitate different procedures than those above. I therefore authorize the above physician and assistants or designees to perform such other procedures that are in the exercise of his other professional judgment necessary and desirable. The authority granted under this paragraph shall include all conditions that require treatment and are not known to my physician at the time the procedure is begun.

3. I acknowledge that no guarantee has been given by anyone as to the results that may be obtained.

4. I consent to be photographed or televised before, during, and after the operation(s) or procedure(s) to be performed, including appropriate portions of my body, for medical, scientific or educational purposes, provided my identity is not revealed by the pictures.

5. For purposes of advancing medical education, I consent to the admittance of observers to the treatment room.

6. IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:

 a. THE ABOVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN

b. THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT

c. THERE ARE RISKS TO THE PROCEDURE OR TREATMENT PROPOSED

CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED ITEMS. I AM SATISFIED WITH THE EXPLANATION.

 

As the patient, I give full consent to allowing my provider to take photos of treatment areas for my chart. I also give full consent to allow photos to be taken at followup appointments for my chart to render the most ideal future plan of care. 

 
As the patient, I understand I will be charge $28 per year for medical clearance.

I GIVE FULL CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED ITEMS. I understand that if I am more than 15 minutes late for my appointment, or I cancel my apportionment less than 48 hours in advance, I will be charged $50, and it will not be refunded.

I understand that injectco's touchup policy is the following: 

1-2 units complimentary for asymmetry after 21 days post treatment

0.1ml - 0.2ml filler for asymmetry after 21 days post treatment

 I understand that under NO CIRCUMSTANCES will any refunds be given. 

*I understand that coupons and specials cannot be retroactively redeemed after treatment has been completed.

I understand if I, as the patient, refuse payment after services are rendered, injectco reserves the right to charge the card on file for the full amount of services applied.