• Dermal Filler Consent

    Treatment with dermal filler as specified by my practitioner can smooth out folds and wrinkles, add volume to the lips, and contour facial features that have lost their fullness due to aging, sun exposure, illness, etc. Facial rejuvenation can be carried out with minimal complications. These dermal fillers are injected into the skin with a very fine needle. The products produce a natural volume under the wrinkle, which is lifted up and smoothed out. The results can often be seen immediately. Treating wrinkles with these dermal fillers is fast and safe and should leave no scars or other traces on the face.

    RISKS AND COMPLICATIONS

    It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure and in this specific instance such risks include but are not limited to:

    Post-treatment discomfort, swelling, redness, and bruising, discolorationPost-treatment infection associated with any transcutaneous injectionAllergic reactionReactivation of Herpes (cold sores)Lumpiness, visible yellow or white patches in approximately 20% of casesGranuloma formationLocalized Necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occurs.Dissatisfaction with the cosmetic result

    PREGNANCY, ALLERGIES & DISEASE

    I am not aware that I am pregnant. I am not trying to get pregnant. I am not Lactating (nursing). I do not have or have not had any major illnesses which would prohibit me from receiving any of the above mentioned dermal fillers. I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to Lidocaine.

    If receiving Collagen I have read the brochure titled "Zyderm®/Zyplast® or CosmoplastTM/CosmodermTMCollagen Explained" in its entirety and have discussed the risks and benefits of injectable collagen treatment with my physician and/or his/her representative and have had all my questions answered. I understand the information provided.

    RESULTS

    I am aware that full correction is important and that follow-up touch ups/treatments will be needed to maintain the full effects. I am aware that the duration of treatment is dependent on many factors including but not limited to: age, sex, tissue condition, my general health and lifestyle conditions, and sun exposure. The correction, depending on these factors may last 3-6 months and in some cases longer. I have been instructed in and understand post-treatment instructions and have been given a copy of them.

    I agree to pay for this treatment. I understand that I have the right to refuse or stop treatment at any time, but that no refunds will be provided once payment is made (including and even if I am dissatisfied with my results). I agree to photos for clinical purposes.

    I hereby voluntarily consent to treatment. The procedure (s) has been explained to me. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure. I certify that if I have any changes occur in my medical history I will notify the office.

    California Arbitration Clause for Medical Release: 

    Any dispute arising from the medical release and related treatment shall be resolved through binding arbitration in accordance with California law. Both parties agree to waive their right to a trial by jury and to participate in class or representative actions. The arbitration will be conducted in a mutually agreed-upon location using the American Arbitration Association (AAA) rules. The arbitrator's decision will be final and binding. Each party will bear their own attorney's fees and share the arbitration costs equally. By signing the medical release, the patient agrees to resolve any disputes through binding arbitration. 

    BY SIGNING BELOW, I ACKNOWLEDGE AND CERTIFY THAT I, HAVE READ AND UNDERSTAND THE "CONSENT, RELEASE AND INDEMNITY AGREEMENT" FOR THIS PROCEDURE, AND THAT I AM SIGNING IT VOLUNTARILY.

    Neurotoxin Informed Consent

    Botulinum Toxin A (Botox/Dysport/Xeomin/Jeuveau/Daxxify) therapy for wrinkles is an injection treatment designed to reduce facial expression lines by enabling the muscles to relax. On the face/neck, Botox/Dysport/Xeomin/Jeuveau/Daxxify therapy works best for "dynamic" lines and wrinkles and is less effective for fine textural changes on the skin surface and for those lines present at rest. Botox/Dysport/Xeomin/Jeuveau/Daxxify therapy for underarm sweating ("hyperhidrosis") is an injection treatment in the axilla causing the sweat glands to cease working in the injected area.

    Botox/Dysport/Xeomin/Jeuveau/Daxxify therapy is temporary, meaning it will have to be repeated on a regular basis to remain effective. An average response is 2 - 6 months of diminished muscle contraction (or underarm sweating if treated there). After a Botox/Dysport/Xeomin/Jeuveau/Daxxify injection, the effect gradually begins over several days and full effect may not be seen until 14 days post-injection.

    Contraindications For This Treatment Include:

    Pregnant or lactating women.Clients with allergies to human albumin (small risk of viral transmission from human albumin used in Type A to provide a larger particle).Infection, inflammation, (including acne), or dermatitis of areas to be injected Fever, flu, or cold symptoms.Facial asymmetry such as Bell's Palsy.Clients with neurologic disorders including:Amyotrophic Lateral Sclerosis (Lou Gherig's Disease).Myasthenia Gravis.Lambert Eaton Disorder.Multiple Sclerosis.Parkinson's disease.

    I am aware of the following information affecting my treatment and risks including but not limited to:

    For at least 6 hours after injection, remain in an upright position; actively contract the muscles treated (e.g. frown or grimace); do not vigorously rub or massage the treated areaAntibiotics may potentiate the effects of Botox/Dysport/Xeomin/Jeuveau/DaxxifyClients taking aminoglycosides or medications that interfere with neuromuscular transmission may have a potentiated effectThick sebaceous skin may have very deep wrinkles making them a poor candidate. A natural eyelid ptosis may be more susceptible to drooping of the eyelid.Botox/Dysport/Xeomin/Jeuveau/Daxxify does not diffuse over scar tissue (the appearance of scar tissue may diminish the following injection of Botox/Dysport/Xeomin/Jeuveau/Daxxify into neighboring wrinkles).Due to bruising potential, you should schedule Botox/Dysport/Xeomin/Jeuveau/Daxify injections at least 2 to 3 weeks prior to an important event.Alcoholic beverages 24 hours prior to Botox/Dysport/Xeomin/Jeuveau/Daxxify injections may increase bruisingBlood-thinning medications and herbal supplements 2 weeks prior and after Botox/Dysport/Xeomin/Jeuveau/Daxxify injections typically increase bruising.

    I am aware of the following risks:

    Mild to moderate discomfort or pain. Many patients describe the sensation as a pinprick.Redness or swelling of the skin at the injection site, usually lasting only a few hours.Bruising in the treated area that may last for several days to several weeks after injections. In rare cases, a bruise may last for longer periods of time.

    Though rare, I am aware the following may also be considered a risk:

    Temporary eyebrow or eyelid drooping and/or double vision may occur if the Botox/Dysport/Xeomin/Jeuveau/Daxxify affects the muscles which move the eye and eyelid.Temporary lip ptosis (drooping) if Botox/Dysport/Xeomin/Jeuveau/Daxxify is used around the mouth area.Transient muscle twitching in the treated area.Transient headache.Infection. Whenever the skin barrier is penetrated infection is possible. Should any type of skin infection occur antibiotics may be necessary.

    I understand that full effects of the treatment may take up to 12 days following the treatment and that if my level of correction is not as I had hoped, I may need to purchase additional Botox/Dysport/Xeomin/Jeuveau/Daxify for injection to reach a higher level of correction. I agree to communicate with my practitioner within two weeks (14 days) for evaluation and/or additional correction.

    I acknowledge that due to my unique skin composition, there are no guarantees, warranties, or assurances that I will be satisfied with my results.

    I understand that this treatment may involve risks of complication from both known and unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been candid in revealing any condition that may have a bearing on this procedure.

    I consent and authorize a staff member of my practitioner, who has been trained in Botox/Dysport/Xeomin/Jeuveau/Daxxify therapy, to perform Botox/Dysport/Xeomin/Jeuveau/Daxxify injections on me. I agree to pay for this treatment. I understand that I have the right to refuse or stop treatment at any time, but that no refunds will be provided once payment is made (including and even if I am dissatisfied with my results).

    I certify that I have read this entire informed consent and that I understand and agree to the information provided in this form as well as the information provided in the Pre/Post Care form. I agree to have my photograph taken to document my condition. My practitioner has explained the nature of my condition, the nature of the procedure, alternative treatments, and the benefits to be reasonably expected compared with alternative approaches. This document is a written confirmation of this discussion.

    I agree that this consent supersedes any previous verbal or written disclosures. This consent is valid for all of my Botox/Dysport/Xeomin/Jeuveau/Daxxify injections in the future as well.

    California Arbitration Clause for Medical Release: 

    Any dispute arising from the medical release and related treatment shall be resolved through binding arbitration in accordance with California law. Both parties agree to waive their right to a trial by jury and to participate in class or representative actions. The arbitration will be conducted in a mutually agreed-upon location using the American Arbitration Association (AAA) rules. The arbitrator's decision will be final and binding. Each party will bear their own attorney's fees and share the arbitration costs equally. By signing the medical release, the patient agrees to resolve any disputes through binding arbitration. 

    BY SIGNING BELOW, I ACKNOWLEDGE AND CERTIFY THAT I, HAVE READ AND UNDERSTAND THIS AGREEMENT FOR THIS PROCEDURE, AND THAT I AM SIGNING IT VOLUNTARILY.

    IV Hydration Consent

    This document is intended to serve as informed consent for your Intravenous (IV) Hydration as ordered by the physician.

    My signature below confirms that I acknowledge that I have informed the nurse and/or physician of any known allergies to medications or other substances and of all current medications and supplements. I have fully informed the nurse and/or physician of my medical history.

    My signature below confirms that I acknowledge that intravenous infusion hydration and any claims made about these infusions have not been evaluated by the US Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any medical disease. These IV infusions are not a substitute for your physician’s medical care.

    My signature below confirms I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent.

    My signature below confirms I understand that:

    The procedure involves inserting a needle into a vein and injecting the prescribed solution.Alternatives to intravenous therapy are oral supplementation and / or dietary and lifestyle changes.Risks of intravenous therapy include but not limited to:Discomfort, bruising and pain at the site of injection.Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.Severe allergic reaction, anaphylaxis, infection, cardiac arrest and death.Benefits of intravenous therapy include:Injectables are not affected by stomach, or intestinal absorption problems.Total amount of infusion is available to the tissues.Nutrients are forced into cells by means of a high concentration gradient.Higher doses of nutrients can be given than possible by mouth without intestinal irritation.

    My signature below confirms that I am aware that other unforeseeable complications could occur. I do not expect the nurse(s) and/or physician(s) to anticipate and or explain all risk and possible complications. I rely on the nurse(s) and/or physician(s) to exercise judgment during the course of treatment with regards to my procedure. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered.

    My signature below confirms that I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. My signature on this form affirms that I have given my consent to IV Infusion Therapy, including any other procedures which, in the opinion of my physician(s) or other associated with this practice, may be indicated.

    My signature below confirms that:

    I understand the information provided on this form and agree with all statements made above.Intravenous (IV) Hydration Treatment has been adequately explained to me by my nurse and/or physician.I have received all the information and explanation I desire concerning the procedure.I authorize and consent to the performance of Intravenous (IV) Hydration Treatment. I release the provider, practice, and all the medical staff from all liabilities for any complications or damages associated with my Intravenous (IV) Hydration Treatment. 

    I agree to pay for this treatment. I understand that I have the right to refuse or stop treatment at any time, but that no refunds will be provided once payment is made (including and even if I am dissatisfied with my results).

    I certify that I have read this entire informed consent and that I understand and agree to the information provided in this form. I agree to have my photograph taken to document my condition.

    California Arbitration Clause for Medical Release: 

    Any dispute arising from the medical release and related treatment shall be resolved through binding arbitration in accordance with California law. Both parties agree to waive their right to a trial by jury and to participate in class or representative actions. The arbitration will be conducted in a mutually agreed-upon location using the American Arbitration Association (AAA) rules. The arbitrator's decision will be final and binding. Each party will bear their own attorney's fees and share the arbitration costs equally. By signing the medical release, the patient agrees to resolve any disputes through binding arbitration. 

    BY SIGNING BELOW, I ACKNOWLEDGE AND CERTIFY THAT I, HAVE READ AND UNDERSTAND THIS AGREEMENT FOR THIS PROCEDURE, AND THAT I AM SIGNING IT VOLUNTARILY.

    Hylenex Consent Form 

    This document is intended to serve as informed consent for your Hylenex treatment as ordered by the physician.

    PURPOSE AND BACKGROUND 

    I have requested hyaluronidase (Hylenex®) injection(s). I understand that these injections are used to dissolve hyaluronic acid filler material. It is used off label to dissolve hyaluronic acid deposits in the skin or the Tyndall effect (blue-ish tint) which can occur if hyaluronic acid fillers are injected too superficially. I understand that this medication can be unpredictable and spread, and may dissolve all the filler that was injected. If the filler was placed by another injector from another facility, I cannot and will not hold this medspa or its employees responsible for any adverse outcome from the use of Hylenex® in attempting to dissolve the product at my request. 

    PROCEDURE

    The Hylenex® will be injected into the area of concern. A series of treatments may be necessary to achieve optimal results. 

    RISKS AND COMPLICATIONS

    Bleeding and Bruising: It is possible, though unusual, to have a bleeding episode from an injection. Bruising in soft tissues may occur. 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. I will not take any of these for 7 days before or after injections.Itching/Swelling/Pain/Redness: The most common side effect is burning on injection. Itching and swelling is also a normal occurrence following the injections. It decreases after a few days. If swelling is slow to resolve, medical treatment may be necessary. Discomfort associated with injections is normal and usually of short duration. Redness in the skin occurs after injections. It can be present for a few days after the procedure. Infection: Although infection is unusual, bacterial, fungal, and viral infections can occur. Herpes simplex virus infections around the mouth can occur following treatment. This applies to both individuals with a past history of Herpes simplex virus infections and individuals with no known history of Herpes simplex virus infections in the mouth area. Specific medications must be prescribed and taken both prior to and following the treatment procedure in order to suppress an infection from this virus. Should any type of skin infection occur, additional treatment including antibiotics may be necessary. Hylenex® should not be injected into or around an infected or acutely inflamed area because of the danger of spreading a localized infection. Allergic Reactions: In rare cases, adverse reactions to hyaluronidase have been known. The allergic reactions are quite rare, but persons with known allergies to hyaluronidase of bovine or ovine origins should not be treated with hyaluronidase. Allergic reactions may include hives, difficulty breathing, and swelling of the face, lips, tongue, or throat. It may even be serious enough to warrant emergency medical treatment. Unknown Risks: The long-term effect of Hylenex® is unknown. The possibility of additional risk factors or complications attributable to the use of Hylenex® may be discovered one day. I understand that it is not uncommon for the treated area to look “over-dissolved or pruned.” This is due to the reaction of native hyaluronic acid in the skin, which is quickly repleted and hydrated. However, since hyaluronic acid is naturally produced in the skin, dissolving it may cause a dimple or depression in the skin when Hylenex® is used which may or may not improve over time. 

    BENEFITS

    Reducing the amount of hyaluronic acid filler material in soft tissue. 

    ALTERNATIVES

    This is strictly a voluntary procedure. No treatment is necessary or required. Other alternative treatments which vary in sensitivity, effect and duration include: plastic surgery for excision. 

    RESULTS

    I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and there can be no guarantee as expressed or implied either to the success or other result of treatment. I am aware that the duration of treatment is dependent on many factors including but not limited to: age, sex, tissue condition, my general health and lifestyle conditions. Clinical results will vary per patient.

    California Arbitration Clause for Medical Release: 

    Any dispute arising from the medical release and related treatment shall be resolved through binding arbitration in accordance with California law. Both parties agree to waive their right to a trial by jury and to participate in class or representative actions. The arbitration will be conducted in a mutually agreed-upon location using the American Arbitration Association (AAA) rules. The arbitrator's decision will be final and binding. Each party will bear their own attorney's fees and share the arbitration costs equally. By signing the medical release, the patient agrees to resolve any disputes through binding arbitration. 

    BY SIGNING BELOW, I ACKNOWLEDGE AND CERTIFY THAT I, HAVE READ AND UNDERSTAND THIS AGREEMENT FOR THIS PROCEDURE, AND THAT I AM SIGNING IT VOLUNTARILY.

    Photo consent

    I hereby grant and authorize my provider the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures or video taken of me to be used in and/or for legally promotional material including, but not limited to, newsletters, flyers, posters, brochures, advertisements, and submissions to websites, social networking sites and other print and digital communications, without payment or any other consideration. This authorization extends to all languages, media, formats and markets now known or hereafter devised. This authorization shall continue indefinitely unless I otherwise revoke said authorization in writing.

    I understand and agree that these materials shall become the property of my provider and will not be returned.

    I hereby hold harmless and release my provider from all liability, petitions, and causes of action which I, my heirs, representative, executors, administrators, or any other persons may make while acting on my behalf or on behalf of my estate.

    I warrant that I am of the age of consent (18 years or older) and that I am competent to contract in my own name. I have read this release before signing below and I fully understand the contents, meaning, and impact of this release.

    PLEASE SIGN YOUR FULL NAME BELOW IF YOU AGREE