Local Anesthesia Consent Form
This form is designed to provide you with the information you need to make an informed decision on whether or not to have local anesthesia during your treatments at Brighton Aesthetics. If you have any questions or do not understand any part of this consent, please do not hesitate to ask us by emailing info@brightonaesthetics.com or calling (810) 852-2514.
I hereby authorize Technicians at Brighton Aesthetics and Wellness Center LLC to use local anesthesia consisting of lidocaine and tetracaine for my comfort during the procedure. I understand that this is solely for my comfort and pain control and is not required for the treatment.
I understand that local anesthetics may contain a “vasoconstrictor” like epinephrine; antioxidants, such as sulfites or methylparaben for preservation of the solutions; sodium hydroxide, and sodium chloride. I understand that local anesthetics will cause the treatment area to become numb, and that the numbness may last up to several hours.
Local anesthetics are commonly used during RF Microneedling and LaseMD treatments. Complications and side effects
are rare, but may include, among others not listed on this sheet:
• Temporary prolonged numbness lasting up to several hours
• Temporary rapid heartbeat.
• Severe and possible life-threatening allergic reactions necessitating emergency care.
• I will inform my Brighton Aesthetics technician if I have uncontrolled high blood pressure, uncontrolled thyroid problem, angina, or have recently had a heart attack, as these conditions have caused complications for persons receiving local anesthesia.
• I will also inform my Brighton Aesthetics technician of any prescription or over-the-counter medications I am taking as these may interact with local anesthetics.
• This consent for local anesthetics remains valid every time I seek any treatment in this office. I have had all of my questions answered and have not been offered any guarantees.
I certify that I am a competent adult of at least 18 years of age, or that if I am a minor under the age of 18, I understand that the consent of my parent/legal guardian/person having legal custody will also be required before treatment.
ACKNOWLEDGMENT
BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS INFORMED CONSENT FOR THE USE OF LOCAL ANESTHESIA, AND THAT I HAVE HAD ALL MY QUESTIONS ANSWERED TO MY SATISFACTION BY BRIGHTON AESTHETICS.