I am requesting that my health care professional perform , that will be referred to as the “Procedure” in the following.
I am requesting the procedure be performed on the
I have discussed the Procedure that I am to receive with my health care professional, I have disclosed all health care conditions and allergies. The nature of this Procedure, the possible complications and risks, as well as the possible benefits of the Procedure, the alternatives to the Procedure and the risks and benefits for those alternatives have been explained to me in language and using terminology that I understand. My health care professional has personally answered all of my outstanding questions about the procedure. I fully understand that this Procedure is an elective aesthetic procedure, and that there is no emergency medical condition that requires that I have the Procedure.
Neither my health care professional nor the staff has made any promises or warranties or guarantees as to the success or effectiveness of the Procedure. I understand that the Procedure may not be effective. I have been advised that I may need several procedures for this Procedure to be effective. I understand that after the Procedure, I may experience side effects such as pain, discomfort and tingling, burning, swelling, bruising, which may be temporary or permanent.
I understand that there are numerous risks and complications, both known and unknown, connected with the Procedure.
I understand that I will need certain post-Procedure care. I will be dutifully responsible in being strictly compliant with the recommendations from my health care professional that may include, but are not limited to ice and compression dressings, etc. I must immediately report any unusual symptoms, know to me, to my health care professional and be especially aware of any slight nature or prominence of persistent chills or fever, redness or increased warmth, excessive bruising or swelling at the site of the injection, fatigue, lethargy, decreased appetite, jaundice (yellowing of skin or the whites of the eyes), dark urine, unusual severe itchiness or abdominal pain.
I give my healthcare professional permission to use data about my treatment for research purposes. I understand that my name and personal identifying information will remain confidential, unless I give written permission to disclose this information. I give my healthcare professional permission to photograph the procedure. I am of clear mind and completely understand the nature of the Procedure and ANY and all possible risks mentions, but NOT limited to all stated risks, which are related to the Procedure. By signing below, I am indicating that I have read and understood the information in this Patient Consent Form, that I have been verbally advised about the Procedure, that I have had an adequate and reasonable opportunity to ask questions, that I have received all the information I desire concerning the Procedure, all of this information is mentally and physically clear to me, and that I authorize and consent to the performance of the Procedure. I release from all liability the medical professional (Mind and Body Renew/A Penny for your Thoughts) performing this procedure as well as the facility where it is being done.
I understand that IM injections can cause ptosis, brow drop, temporary paralysis of muscles can occur however my provider takes every accommodation to prevent such events from occurring . I understand that fillers can cause vascular occlusion , however my provider will make every effort to prevent a vascular occlusion. In the event of a suspected vascular occurrence, i will notify my provider immediately , start taking Aspirin 81 mg Per day, increase my intake of garlic , massage vigorously and use heat.