I understand that as part of my healthcare, the healthcare providers of 4 You LLC. originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information is utilized to plan my care and treatment, to bill for services provided to me, to communicate with other healthcare providers and other routine healthcare operations such as assessing quality and reviewing competence of healthcare professionals. 4 You LLC. Notice of Privacy Practices provides specific information and complete description of how my personal information may be used and disclosed. I understand that a copy of the Notice of Privacy Practices is available at the front desk and understand that I have the right to review the notice prior to signing this consent. I understand that 4 You LLC. reserves the right to change the Notice of Privacy Practices. Prior to implementation of the revised Notice of Privacy Practices, there vised Notice will be mailed to me if I provide my address below. I understand I have the right to restrict the use and/or disclosure of my personal health information for treatment, payment, or healthcare operations and that 4 You LLC. is not required to agree to the restrictions requested. I may revoke this consent at any time in writing except to the extent that 4 You LLC. has already taken action in reliance on my prior consent. This consent is valid until revoked by me in writing. We may change our policies and this notice at any time and have those revised policies apply to all the protected health information we maintain. If or when we change our notice, we will post the new notice in the office where it can be seen. You can request a paper copy of this notice, or any revised notice, at any time (even if you have allowed us to communicate with you electronically). For more information about this notice or our privacy practices and policies, please contact the person listed at the end of this document.

NOTE: 4 You LLC. must obtain your written authorization to use your Private Health Information for any purpose other than treatment or billing. If you want 4 You LLC. to have access to disclose your Private Health Information to your spouse or any other person during your treatment, please sign below.

This information is for use by the parties named above only, and may not be disclosed to any other individual or agency without the patient’s consent or as otherwise provided by law. This authorization is subject to revocation at any time except to the extent the 4You, LLC has already taken action in reliance on it.

I understand that the information in my medical records may include information related to sexually transmitted disease, AIDS/HIV testing or diagnosis, mental health services, or drug/alcohol abuse diagnosis or treatment, and/or AIDS (Acquired Immunodeficiency Syndrome). Information in the form of audio, photo, or video has been designated above, if applicable.

I understand that 4 You, LLC, Ashley Caldwell, Certified Nurse Practitioner with NPI: 790336741, will not withhold health care if I do not sign this consent, but that exchange of private information with an outside entity such as a future employer or consulting physician will not be made without my consent. A copy of this consent and annotation concerning the persons or agencies with which information was exchanged will be included in my medical records. I understand that health information exchanged under this consent might be redisclosed by a recipient and no longer be protected by privacy laws.

Instructions:

This is an informed consent documents, which has been prepared to help the nurse practitioner or nurse to inform you concerning Botox® (Botulina Toxin Type A : Allergan), Jeuveau ® (Botulina Toxin A: Evolus), Xeomin ® (Botulina A Toxin: Merz), and other toxins injections, risks, and alternative treatment.

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 nurse practitioner or provider.

General Information:
Clostridium, botulinum bacteria produces a class of chemical compounds known as "toxins". The bottom line to type a toxin is processed and purified to produce a sterile product suitable for specific therapeutic uses. Once the deluded tocsin is injected, it produces a temporary paralysis (chemodenervation) of the muscle, by preventing transmission of nerve impulses to the muscle. The duration of the muscle paralysis generally last for approximately 3 to 4 months.

Botox®, Jeuveau ®, Xeomin ®, and other toxins are customized for every patient, depending on his or her particular needs. These can be performed in areas involving the area around the eyes (Crow's feet), glabellar region (area between the eye brows), peri oral region, forehead, lip, amount several other on and off label treatment areas.

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.

Risk of injections

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 Nurse Practitioner to make sure you understand risks, potential complications, limitations, and consequences of BOTOX® , Xeomin®, and Jeuveau®  injections.

Additional information concerning  may be obtained from the package-insert sheets available upon request.

Incomplete Block: It is possible to not experience a complete block of desired muscles. Additional injections to reach the desired level of block can be performed until the goal is achieved.

Asymmetry: The human face and eyelid region is normally asymmetrical with respect to structural anatomy and function. There can be a variation from one side to the other in terms of the response to BOTOX® ,Xeomin®, and Jeuveau®   injections.

Drooping Eyelid (Ptosis): Muscles that raise the eyelid may be affected by BOTOX®  and Xeomin®   , should this material migrate downward from other injection areas.

Pain: Discomfort associated with BOTOX®, Xeomin®, and Jeuveau®injections is usually of short duration.

Migration: BOTOX®, Xeomin®, and Jeuveau® may migrate from its original injection site to other areas and produce temporary paralysis of other muscle groups or other unintended effects. BOTOX®, Xeomin®, and Jeuveau® has been reported to cause swallowing problems in patients treated for spastic muscle disorders of the cervical region (cervical dystonia).

Bleeding and Bruising: It is possible, though unusual, to have a bleeding episode from a BOTOX® , Xeomin®, and Jeuveau® injection. Bruising in soft tissues may occur. Serious bleeding around the eyeball during deeper BOTOX® , Xeomin®, and Jeuveau® injections for crossed eyes (strabismus) has occurred. 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 these for ten days before or after BOTOX® ,Xeomin®, and Jeuveau® injections.

Damage to Deeper Structures: Deeper structures such as nerves, blood vessels, and the eyeball may be damaged during the course of injection. Injury to deeper structures may be temporary or permanent.

Corneal Exposure Problems: Some patients experience difficulties closing their eyelids after BOTOX®  and Xeomin®   injections and problems may occur in the cornea due to dryness. Should this rare complication occur, additional treatments, protective eye drops, contact lenses, or surgery may be necessary.

Unknown Risks: The long-term effect of BOTOX®, Xeomin®, and Jeuveau® on tissue is unknown. The risk and consequences of accidental intravascular injection of BOTOX®  and Xeomin®  is unknown and not predictable. There is the possibility that additional risk factors may be discovered.

Dry Eye Problems: Individuals who normally have dry eyes may be advised to use special caution in considering BOTOX injections around the eyelid region.

Double-Vision: Double-vision may be produced if the BOTOX®, Xeomin®, and Jeuveau® material migrates into the region of muscles that control movements of the eyeball.

Eyelid Ectropion: Abnormal looseness of the lower eyelid can occur following BOTOX®, Xeomin®, and Jeuveau®  injections.

Other Eye Disorders: Functional and irritative disorders of eye structures may rarely occur following BOTOX® ,Xeomin®, and Jeuveau® Injections.

Blindness: Blindness is extremely rare after  injections. However, it can be caused by internal bleeding around the eyeball or needle stick injury. The occurrence of eye problems appears to be very rare.

Allergic Reactions: As with all biologic products, allergic and systemic anaphylactic reactions may occur. Allergic reactions may require additional treatment.

Antibodies to BOTOX®, Xeomin®, and Jeuveau® injections: Presence of antibodies to BOTOX may reduce the effectiveness of this material in subsequent injections. The health significance of antibodies to BOTOX is unknown.

Infection: Infection is extremely rare after BOTOX®  and Xeomin® injections. Should an infection occur, additional treatment including antibiotics may be necessary.

Skin Disorders: Skin rash, itching, and swelling may rarely occur following BOTOX®, Xeomin®, and Jeuveau® injections,

Neuromuscular Disorders: Patients with peripheral motor neuropathic disorders (amyotrophic lateral sclerosis myasthenia gravis, motor neuropathies) may be at greater risk of clinically significant side effects from BOTOX®, Xeomin®, and Jeuveau®  injections.

Migraine Headache Disorders BOTOX®, Xeomin®, and Jeuveau® injections has been used to treat forehead muscle groups that are involved with the migraine headache condition. Patients are advised that results of BOTOX®, Xeomin®, and Jeuveau®  treatments for migraine headaches may be variable and improvement in this disorder may not occur following BOTOX®, Xeomin®, and Jeuveau®  injections

Unsatisfactor Result: There is the possibility of a poor or inadequate response from BOTOX®, Xeomin®, and Jeuveau®  injections. Additional BOTOX®, Xeomin®, and Jeuveau®  injections may be necessary. Surgical procedures or treatments may be needed to improve skin wrinkles including those caused by muscle activity.

Long-Term Effects: Subsequent alterations in face and eyelid appearance may occur as the result of aging, weight loss, weight gain, sun exposure, pregnancy, menopause, or other circumstances not related to BOTOX®, Xeomin®, and Jeuveau® injections. BOTOX®, Xeomin®, and Jeuveau® injections do not arrest the aging process or produce permanent tightening of the eyelid region. Future surgery or other treatments may be necessary.

Pregnancy and Nursing Mothers: Animal reproduction studies have not been performed to determine if BOTOX®, Xeomin®, and Jeuveau® injections could produce fetal harm. It is not known if BOTOX®, Xeomin®, and Jeuveau® injections can be excreted in human milk. It is not recommended that pregnant women or nursing mothers BOTOX®, Xeomin®, and Jeuveau®  injections treatments.

Drug Interactions: The effect of BOTOX®, Xeomin®, andJeuveau® injections may be potentiated by aminoglycoside antibiotics or other drugs known to interfere with neuromuscular transmission.

GENERAL RISKS
Bleeding: It is possible, though unusual, to experience a bleeding episode during or after procedure. Should post- operative bleeding occur, it may require emergency treatment to drain accumulated blood or you may require a blood transfusion, though such occurrences are rare. Increased activity too soon after procedure can lead to increased chance of bleeding and additional procedures. It is important to follow postoperative instructions and limit exercise and strenuous activity for the instructed time. Do not take any aspirin or anti-inflammatory medications for at least ten days before or after procedure, as this may increase the risk of bleeding. Non-prescription “herbs” and dietary supplements can increase the risk of surgical bleeding. Hematoma can occur at any time, usually in the first three weeks following injury to the procedural area. If blood transfusions are necessary to treat blood loss, there is the risk of blood-related infections such as hepatitis and HIV (AIDS). Heparin medications that are used to prevent blood clots in veins can produce bleeding and decreased blood platelets.

Infection: Infection is unusual after procedure. Should an infection occur, additional treatment including antibiotics, hospitalization, or additional surgery may be necessary. It is important to tell your Nurse Practitioner or Nurse of any other infections, such as ingrown toenail, insect bite, or urinary tract infection. Remote infections, infections in other parts of the body, may lead to an infection in the operated area.

ADDITIONAL ADVISORIES

Female Patient Information: It is important to inform your Nurse Practitioner or Nurse if you use birth control pills, estrogen replacement, or if you suspect you may be pregnant. Many medications including antibiotics may neutralize the preventive effect of birth control pills, allowing for conception and pregnancy.

Mental Health Disorders and Elective Procedure: It is important that all patients seeking to undergo elective procedure have realistic expectations that focus on improvement rather than perfection. Complications or less than satisfactory results are sometimes unavoidable, may require additional procedures and often are stressful. Please openly discuss with your Nurse Practitioner or Nurse, prior to procedure, any history that you may have of significant emotional depression or mental health disorders. Although many individuals may benefit psychologically from the results of elective procedure, effects on mental health cannot be accurately predicted.

Sun Exposure – Direct or Tanning Salon: The effects of the sun are damaging to the skin. Exposing the treated areas to sun may result in increased scarring, color changes, and poor healing. Patients who tan, either outdoors or in a salon, should inform their Nurse Practitioner or Nurse and either delay treatment, or avoid tanning until the Nurse Practitioner or Nurse says it is safe to resume. The damaging effect of sun exposure occurs even with the use of sun block or clothing coverage.

Medications and Herbal Dietary Supplements: There are potential adverse reactions that occur as the result of taking over-the-counter, herbal, and/or prescription medications. Aspirin and medications that contain aspirin interfere with clotting and can cause more bleeding. These include non-steroidal anti-inflammatories such as Motrin, Advil, and Aleve. It is very important not to stop drugs that interfere with platelets, such as Plavix, which is used after a stent. It is important if you have had a stent and are taking Plavix that you inform the Nurse Practitioner or Nurse. 

Stopping Plavix may result in a heart attack, stroke and even death. Be sure to check with your physician about any drug interactions that may exist with medications which you are already taking. If you have an adverse reaction, stop the drugs immediately and call your Nurse Practitioner or Nurse for further instructions. If the reaction is severe, go immediately to the nearest emergency room. When taking the prescribed pain medications after procedure, realize that they can affect your thought process and coordination. Do not drive, do not operate complex equipment, do not make any important decisions and do not drink any alcohol while taking these medications. Be sure to take your prescribed medication only as directed.

Travel Plans: Any procedure holds the risk of complications that may delay healing and delay your return to normal life. Please let the Nurse Practitioner or Nurse know of any travel plans, important commitments already scheduled or planned, or time demands that are important to you, so that appropriate timing of procedure can occur. There are no guarantees that you will be able to resume all activities in the desired time frame.

Off-Label FDA Issues: 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”, that 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. BOTOX®, Xeomin®, and Jeuveau® injections is approved for Glabellar frown lines, crow’s feet, forehead, marionette lines, infra brow, chin, neck, nasalis, masseter, Blepharospasm, and would be Off-Label for all other uses. 

Cosmetic Surgical is a unique practice and is considered a form of alternative medicine. Even though the physicians and nurses are board certified as medical doctors, nurses, nurse practitioners and/or physician assistants. Most health insurance companies exclude coverage for cosmetic surgical operations, or any resulting complications Please carefully review your health insurance subscriber-information pamphlet. Most insurance plans exclude coverage for secondary or revisionary procedure due to complications of cosmetic procedure.

Insurance companies are not obligated to pay for our services (consultations, insertions or pellets, or any other work done through our facility). We require payment at time of service. WE WILL NOT, however, communicate in any way with insurance companies.

 This form and your receipt are your responsibility and serve as evidence of your treatment. We will not call, write, pre-certify, appeal nor make any contact with your insurance company. If we receive a check from your insurance company, we will not cash it but will return it to the sender. Likewise, we will not mail it to you. We will not respond to any letters or calls from your insurance company.

There are many variable conditions in addition to risk and potential complications that may influence the long-term result of BOTOX®, Xeomin®, and Jeuveau® injections. Even though risks and complications occur infrequently, the risks cited are the ones that are particularly associated with BOTOX®, Xeomin®, and Jeuveau® injections. 

The cost of BOTOX®, Xeomin®, and Jeuveau® injections may involve several charges. This includes the professional fee for the injections, follow-up visits to monitor the effectiveness of the treatment, and the cost of the BOTOX®, Xeomin®, and Jeuveau® injections material itself. It is unlikely that BOTOX®  and Xeomin®  injections to treat cosmetic problems would be covered by your health insurance. The fees charged for this procedure do not include any potential future costs for additional procedures that you elect to have or require in order to revise, optimize, or complete your outcome. Additional costs may occur should complications develop from the injections and will also be your responsibility. In signing the consent for procedure, you acknowledge that you have been informed about its risks and consequences and accept responsibility for the clinical decisions that were made along with the financial costs of all future treatments.

Informed-consent documents are used to communicate information about the proposed treatment of a disease or condition along with disclosure of risks and alternative forms of treatment(s), including no procedures. 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 Nurse Practitioner may provide you with additional or different information which is based on all the facts in 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.

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

1. I hereby authorize the Nurse Practitioner or Nurse to perform the following procedure or treatment: BOTOX®, Xeomin®, and Jeuveau®  injections. I have received the following information sheet: INFORMED CONSENT – BOTOX®, Xeomin®, and Jeuveau® injection.
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 or her 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 consent to the administration of such anesthetics considered necessary or advisable. I understand that all forms of anesthesia involve risk and the possibility of complications, injury, and sometimes death.
4. I understand what my Nurse Practitioner or Nurse can and cannot do, and I understand there are no warranties or guarantees, implied or specific about my outcome. I have had the opportunity to explain my goals and understand which desired outcomes are realistic and which are not. All of my questions have been answered, and I understand the inherent (specific) risks of the procedures I seek, as well as those additional risks and complications, benefits, and alternatives. Understanding all of this, I elect to proceed.
5. 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.
6. For purposes of advancing medical education, I consent to the admittance of observers to the treatment room.
7. I authorize the release of my Social Security number to appropriate agencies for legal reporting and medical- device registration, if applicable.
8. I understand that the Nurse Practitioner’s or Nurse's fees are separate from the anesthesia and hospital charges, and the fees are agreeable to me. If a secondary procedure is necessary, further expenditure will be required.
9. I realize that not having the operation is an option.
10. 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

The treatment is quick and easy with minimal down time. You will begin to notice results within 7-10 days and will last up to 3 months. Results are based on multiple factors. On average most patients receive 20 units in forehead, 20 units in glabellar area (above and between eye brows), and 20 in crow’s feet area. Doses may vary depending on your specific treatment plan and muscle strength!  These products are both meant to relax the muscles in the face to stop you from making the lines from muscle movement (dynamic wrinkles).  These products DO NOT resurface the skin where wrinkles are present at rest (static lines).  These products will however stop these static lines from worsening.  Dermal filler in combination with these products will correct the undesired static wrinkles.  Don’t hesitate to ask questions!

Pre-visit instructions:  Please adhere to COVID guidelines including social distancing an wearing a mask.  Mask is required unless actively being treated in that area.  If you have a fever, shortness of breath, cough, sore throat, loss of taste or smell, severe headache, or abdominal pain we will ask that you re-schedule.  We apologize for the inconvenience.

Please refrain from using NSAIDS (Aleve, ibuprofen, Advil, meloxicam, etc), aspirin, as well as fish oil for 48 hours prior to appointment to reduce bruising.  If you are on anticoagulants (coumadin, Xarelto, Eliquis, etc) please do not stop those medications, but please understand the risk of bleeding and bruising are significantly increased.

Post-visit instructions:  Keeping the neurotoxin in the space injected is critical and vital to achieve your desired results and reduce risk for complications such as droopy eyelid, eye brows, etc.  For the first 4 hours after injection, please avoid rubbing the areas injected as well as the surrounding areas.  If you must rub, only do so lightly and always rubbing up, not down.  You should also avoid frequent bending over such as doing laundry, dishes, painting, cooking, and so on.  Please avoid strenuous physical activity and stay upright for at least 4 hours after injection. No sleeping until 4 hours also!  Refrain from applying makeup and lotions/creams for at least 2 hours after injection to reduce irritation/infection.

Alcohol: Alcohol increases risk of bleeding/bruising.  Please avoid consuming alcohol 48 hours before and after treatment for optimal results.