• Botox/Xeomin Consent

  • We are 100% committed to the health and well-being for everyone. We are doing everything we can to keep potential exposure out of our office.

    As part of the local and state guidelines you must answer no to all the following questions each time you enter Pua Manu MedSpa.

    Not present a fever over 100 F/ 37 C.
    Not presenting cold, cough, difficulty breathing muscle pain, headache,
    loss of taste/smell or pink eye in past 5 days.
    Not in contact with anyone with these symptoms in the past 5 days.
    Not in contact with anyone diagnosed with COVID-19, sick and quarantined, in the past 5 days.
    All information above is true. I may be asked again when I arrive for my appointment. 
    ALL PATIENTS AND STAFF ARE REQUIRED TO: 

    Stay home if you are sick or are exhibiting symptoms of illness such as a fever or persistent cough.
    Face mask are required to enter the Spa.
    Refrain from shaking hands or other touching rituals.
    Wash hands for 60 seconds with soap and warm water prior to treatment or use hand sanitizer.
    Refrain from eating or drinking while in the Spa, face mask should not be removed. 
    I understand that Pua Manu MedSpa has put in place reasonable safety measures to help reduce the spread of COVID-19.

    I understand that I am consenting to an elective treatment/procedure that is not urgent or emergent. I understand that it may put me at increased risk for becoming infected with COVID-19, due to potential community exposure.

  • Patient acceptance*

  • Botox and Xeomin is a brand name for botulinum toxin-type A, a neurotoxin that blocks messages between muscles and nerves that control them.

    The FDA has approved the use of Botox and Xeomin to treat facial dystonias (spasms), strabismus (crossed eyes), and to temporarily soften facial rhytids (wrinkles) between the eyebrows and crows feet. While the FDA has not approved injections to improve the appearance of wrinkles in other areas of the face, physicians may perform these “off label” procedures.

    The temporary effects of Botox/Xeomin become apparent 2-5 days after the injection is given and generally last 4-6 months. There are alternatives to Botox/Xeomin which include medications, surgery on facial nerves and muscles or no treatment.

    Side Effects and Complications include but are not limited to:

    • Bruising
    • Under-correction (not enough effect) or overcorrection (too much effect)
    • Facial asymmetry (one side looks different than the other)
    • Droopy eyelid, double vision, inability to close eye, drinking from a straw
    • Generalized weakness
    • Permanent loss of muscle tone with repeated injection
    • Flu-like symptoms or respiratory infection, nausea or headaches
    • Development of antibodies
    • Derived albumin and carries a theoretic risk of virus transmission.
    • There have been no reports of disease transmission.

    Contraindications:

    • You should not have Botox/Xeomin if you are allergic to albumin, pregnant, nursing, have an infection, or have Eaton-Lambert Syndrome, Lou Gehrig’s disease, or myasthenia gravis. No guarantees regarding results have been made.

    The potential benefits of Botox/Xeomin have been explained along with alternative methods.

  • I understand that Botox/Xeomin is an elective procedure, that insurance does not cover this procedure and that I am solely responsible for payment. Fee structure and payment have been fully explained to me. I understand that the amount due depends on the amount of units Dr. Nancy Chen uses.*
  • Discounted or special priced treatments must be prepaid in full by first treatment appointment. Incomplete and/or cancelled treatments will be charged at regular/full price, NO refunds. *
  • I understand that necessary photos will be taken before, during and after the course of my treatments for medical purposes and to evaluate treatment effectiveness. I understand that my photos will be kept confidential in my electronic patient record*
  • I consent to photographs and other audio-visual and graphic materials before, during and after the course of my treatments to be used for marketing and medical educational purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I may or may not be identified by the photos.
  • I have read and understand all information presented to me before signing this consent form. I have been given an opportunity to have all of my questions answered to my satisfaction. I understand the procedure and accept the risks. I authorize the provider to administer Botox/Xeomin injections today and for future treatments as needed.
  • I assume all risks as my own and agree to hold harmless, Pua Manu MedSpa. their providers, estheticians, and any other staff member, affiliate, or independent contractor. I hereby release them from any liability, both seen and unforeseen, now and forever.
  • Date*
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