Being fully informed about your condition and treatment will help you make the decision whether to undergo treatment. This disclosure is an effort to make you better informed, so you may give or withhold your consent to the procedure. As with any cosmetic procedure, you should not receive this treatment if you have unattainable expectations.

I have requested that the medical staff at TKI attempt to improve my facial lines and enhance facial shaping with injectable Neuromodulators and/or dermal fillers. These injections have been used to improve spasm of the muscles around the eye, to correct double vision due to muscle imbalance as well as numerous other neurological uses.

Neuromodulator is approved by the FDA to improve the appearance of the vertical lines between your brows. Injections in other areas to improve appearance of facial lines and for facial shaping have been well documented in the literature, although considered "off label" uses. The results of Neuromodulator are usually dramatic although the practice of medicine is not an exact science and no guarantees can be or have been made concerning expected results. am aware that office policy is that there are no refunds or credit given for dissatisfaction or undesirable results. The Neuromodulator solution is injected with a needle into the skin and muscle. You should see the benefits develop over the next two to fourteen days. A decreased appearance of frowning or creasing of other lines and/or a change in specific facial grimacing will be the result of this treatment. The most common side effects are headaches, respiratory infection, flu syndrome, temporary eyelid droop, and nausea. Neuromodulator should not be used if there is an infection at the injection site. Additionally, bruising may occur at the injection site. have been advised of the risks involved in such treatment, the expected benefits of such treatment and alternative treatments, including no treatment at all. understand that the results are temporary and repeat treatments are needed to maintain the desired results.

TKI staff has explained the use of and addiction to fillers including the following: Fillers are a sterile, clear, colorless dermal filler gel implants made of chemically modified hyaluronic acid derived from Streptococcus bacteria. Radiesse is a resorbable implant product approved by the FDA for the correction of moderate to severe facial wrinkles and folds. Fillers are injected just beneath the skin surface, and occasionally in deeper planes, temporarily adding volume to the layers of the skin that have deteriorated due to age and other factors. Fillers are used to raise depression in the skin, providing temporary correction of wrinkles and folds. Fillers are made from highly purified natural hyaluronic acid that is gradually absorbed by your body through natural mechanisms. Fillers have various FDA approvals for use in various locations and by signing this consent I acknowledge that location, choice of filler, and placement of filler has been discussed with me. Risks and benefits including long term and irreversible risks have been discussed with me as well.

I understand the nature and potential consequences of these injections. Ihavebeenspecifically informed of the following:After the injection,some common injection-related reactions might occur such as swelling, redness, pain, itching, bruising, skin discoloration and tenderness which begins early after the injection and generally lasts less than 7 days. Although the injection material is generally not visible through the skin, some patients have reported that they were initially able to feel the outline of the injected material. I understand that there is a risk that small lumps may form under my skin due to the filler material collecting in one area. It is possible for the needle to be accidentally placed through a blood vessel during injection, which could result in a permanent change in color or in tissue death in the treated area leading to a scab and/or scar formation, permanent disfiguration, blindness, and/or other serious complications secondary to embolization. understand that if filler blocks a blood vesselor compresses a vessel, it could cause damage of potentially large areas of distant tissue, or potentially even a heart attack, stroke, or blindness. As with all transcutaneous procedures, understand that injection of any filler material carries the risk of infection, scar tissue formation, or granuloma formation. I understand that there is a risk that injection of filler material carries the risk of recurrence of an outbreak of herpes and that the outbreak may be severe in mature. I understand that filler material may move from the place where it was injected. I understand that the safety of filler in patients with known susceptibility to recurrent sore throat or Osler Rendu endocarditis has not been studied. I understand that the safety of injecting filler in volumes greater than 6.0mL per year has not been studied. understand that the interaction of filler with drugs or other substances or implants has not been studied. | understand that medical attention may be required to resolve complications associated with my injections. Fillers should not be used in patients with severe allergic reactions, a history of anaphylaxis, or history or presence of multiple severe allergies or hypersensitivity to any of the ingredients of the various fillers listed above. Certain Fillers are radiopaque and are visible on CT scans and x-rays.

Patients who are using substances that can prolong bleeding, such as aspirin, non-steroidal anti-inflammatory drugs and warfarin may, as with any injection, have increased bruising or bleeding at injection sites. Within the first 24 hours, patients should avoid strenuous exercise, extensive sun or heat exposure and alcoholic beverages as exposure to these may cause temporary redness and swelling at injection site. Over time, fillers will be absorbed by the body; this is why patients may desire ongoing treatments. If a patient chooses not to continue with treatment, any remaining filler is simply absorbed by the body over time and the skin gradually returns to its natural shape.

I know that the practice of medicine and surgery is not an exact science and therefore, a reputable physician cannot guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the filler injection that have herein requested and authorized. have been advised that the goal is improvement in my appearance, that imperfections may ensue, and that the results might not live up to my expectations or the goals that have been established. may be dissatisfied with the results. am aware that office policy is that there are no refunds or credit given for dissatisfaction or undesirable results and that have the option to dissolve the dermal filler.

I hereby give permission to TKI staff to take photographs for diagnostic purposes and adequate recordings in my medical records. I agree that these photographs will remain in her property. To my knowledge, I am not allergic to any bacterial products.I certify that have read all applicable information pertaining to this procedure and completed a patient registration and medical history form fully and correctly to the best of my knowledge, and that the information have supplied is complete and correct. I understand that if TKI staff judges at any time that my injection should be postponed or cancelled for any reason, they may do so. I have read the above consent fully, understand the same, and do authorize TKI staff to perform the filler injection. By signing below, I acknowledge that have read the foregoing informed consent, have had the opportunity to discuss any questions that have with my provider to my satisfaction, and consent to be treatment described above with its associated risks. understand that have the right not to consent to this treatment and that my consent is voluntary. understand that by signig below am verifying that am not pregnant or have any medical conditions that are contraindicated. I hereby release the doctor, the person performing the injection and the facility from liability associated with this procedure. understand that will be injected with the filler in have been given an opportunity to ask any questions I desired regarding the matters covered in the preceding paragraphs, and these questions have been answered to my satisfaction. I understand that will be injected with the filler in the following areas: 

I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I certify that have read and fully understand the above paragraphs and that have had sufficient opportunity for discussion and to ask questions.I consent to this injection treatment today and for all subsequent treatments.