City Injectables consent form

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone

E-mail

DOB

Date

Medications

Allergies

Medical Conditions

Have you had any of the following conditions, tick all that apply

Concerns

I understand the nature of the procedure/s.

I confirm I have read and understand the before care instructions sent to me.

I confirm that all risks and benefits of the procedure/s have been explained to me and are fully understood by myself.

I acknowledge that I have been advised of the risks of this procedure/s.

I am aware that the procedure/s is not an exact science and that the results cannot be guaranteed.

No such guarantee has been given to me as to the results of this procedure/s.

I consent that I do not suffer from any of the contraidications listed for this procedure/s.

I certify that I am at least 18 years old or I have parental consent co-signed below.

I agree that this constitutes full disclosure, and that it supercedes any previous verbal or written disclosures.

I certify that that I have read, and fully understand the information given to me, and that I have had sufficient opportunity for discussion and to ask questions.

I consent to this procedure/s today and for all subsequent treatments.

Signature*

Prescription Form

Medication –
Botulinum Toxin Type A 100 units/vial (OnabotulinumtoxinA)
Botulinum Toxin Type A 100 units/vial (Letibotulinum toxin typeA)
Botulinum Toxin Type A 500 ISPEN units/vial (Clostridium botulinum toxin typeA)
Hylaluronic Acid 20mg/ml, 18mg/ml, 24mg/ml or per product make.
Xylocaine 2% 100mg/5ml for injection
Lignocaine 2% 100mg/5ml for injection
Adrenaline (epinephrine) 1mg/1ml
Benzocaine 20% Lignocaine 10% Tetracaine 4% in versabase cream
Deoxychloric Acid 20mg/2ml (10mg/ml)
Hyaluronidase 1500iu per vial
Sculptra Poly-L-lactic acid 150mg per vial
Profhilo 3.2% -32mg (H-HA) +32mg (L-HA)/2ml Hyaluronic acid sodium salt

Directions for use – Facial tissue augmentation, muscle relaxation, fat dissolving, anaesthetic, the treatment of fine lines & wrinkles, dissolving hyaluronic acid treatments, emergency anaphaylactic reaction.
To be administered by: Registered Nurse
To be administered at: Injex Clinics – 1A, 8-16 Redland Bay Rd, Cnr Dollery Rd, Capalaba, QLD, 4157
Injex Clinics - 1401 Gympie Rd, Aspley, Qld, 4034
Injex Clinics - Shop 28, 1 Springfield Lakes Blvd, Springfield Lakes, Qld, 4300

Botulinum toxin type A treatment:
Frown/glabella – up to 60units dysport or up to 30units botox/Letybo.
Forehead/frontalis – up to 60units dysport or up to 40units botox/Letybo.
Crows feet – up to 120units dysport or up to 60 units botox/Letybo. Masseter muscles – up to 200 units dysport
Platysmal bands – up to 80 units dysport or up to 40units botox/Letybo
Nasal lines /compressor naris – up to 20 units dysport or up to 10units botox/Letybo
Nasal flare/dialator naris – up to 20 units dysport or up to 10units botox/Letybo
Gummy smile/levator labii superioris alaeque nasi – up to 12 units or up to 6 units botox/Letybo
Depressor Anguli Oris/Marionette lines – up to 20 units dysport or up to 10units botox/Letybo
Upper lip lines/ vermillion border – up to 24 units dysport or up to 12units botox/Letybo
Mentalis/chin – up to 20 units dysport or up to 10units botox/Letybo
Axillar for hyperhidrosis – up to 200u/side dysport or up to 100 units botox/Letybo

Hyaluronic acid treatment:
Croma, Restylane & Profhilo range up to 10ml per treatment - needle and cannula using bolus and linear thread technique for deep dermal, to subdermal enhancement.
Areas for injection: Lips,Cheeks, Nasolabial folds,Marionette lines, Oral
commissures, Accordians, Chin,Jaw line,Jaw enhancement,Nasojugal groove,Tear trophs,Full face facial hydration, Temples,Fine lines on face, neck and décolletage,Hands and Fingers

Deoxychloric Acid treatment:
Deoxychloric Acid Solution up to 8ml per treatment – for treatment of submental adipose tissue using cannula and needle techniques.

Hyaluronidase treatment:
Hyaluronidase for the treatment of dissolving excess hyaluronic acid PRN.

Sculptra Poly-L-lactic Acid treatment:
Sculptra Poly-L-lactic Acid up to 5 vials per treatment - for treatment of subcutaneous or deep dermis injection.

Anaesthetic treatment:
Xylocaine with adrenaline up to 5ml/50mg intercostals (per nerve) max. 50ml/150mg for production of local or regional anaesthesia by nerve block
Lignocaine up to 5ml/50mg intercostals (per nerve) max. 50ml/150mg for production of local or regional anaesthesia by nerve block
Benz/Ligno/Tetracaine cream up to 15ml for localised topical anaesthesia

Adrenaline treatment:
Adrenaline for the emergency treatment of anaphylaxis up to 0.6mg intramuscular injection.

I, have viewed the patient and their medical history and deem them to be
eligible for treatment by the Registered Nurse.

Dr. Alex Ha
Injex Clinics
Prescriber number: 2244552

Dr. David Seton
Injex Clinics
Prescriber number:
2109442

Dr. Arun Nayak
Injex Clinics
Prescriber number:
2328560

Consultation performed:

Past medical history, medications, allergies, cosmetic procedure history discussed. Treatment goals and treatment plan discussed. No contraindications to treatment. BDD negative. Client given opportunity to ask questions.

Dr Signature

Prescribing Doctor*

Doctors notes