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Informed Consent

BOTOX

(Used interchangeably for Botulinum Toxin) Improves wrinkles by causing muscles to decrease function or become paralyzed. This decrease in muscle function is temporary and should be repeated in 3 months. Weakness of adjacent muscles may occur because of the spread of the botulism.

Side effects include, but not limited to, those listed below as well as: temporary ptosis; lid changes; corneal exposure, resulting in impaired or double vision (which is usually temporary); reduced blinking (associated with corneal ulcerations).

An auto renewable membership may be purchased to include injections for just eight dollars per unit for six months.

DERMAL FILLER

For facial contouring or diminishing the appearance of wrinkles. Lasts up to 6 months or longer. By signing this consent form, I am confirming that I not have severe allergies, particularly allergies to bacterial proteins, which precludes treatment.

KYBELLA

Improves submental fat, "double chin." Multiple monthly treatments are required. Side effects include, but are not limited to: nerve injury, causing uneven smile or facial muscle weakness (usually self-limited); temporary trouble swallowing (likely due to neck swelling); skin erosions; hair loss; more noticeable platysma bands; visual deformities.

MIC B12

Improves memory, increases energy, aids in weight management. MIC B12 injections help convert fats to energy. Supplements or medicine may cause side effects when used with MIC B12.An auto renewable membership membership may be purchased to include weekly Injections for six months.

MICRONEEDLING WITH PRP

For skin rejuvenation and hair loss. Multiple treatments are needed. Side effects include, but are not limited to those listed below.

CHEMICAL PEEL

Side effects listed below.

PDO THREAD LIFT

Used to soften wrinkles,lift and tighten skin, and stimulate collagen production. Lasts up to 2 years. Risk/side effects, in addition to those listed below, include partial: correction requiring re-treatment; scarring; visible threads; irregularity or dimpling of skin; hematoma; pigment changes to skin; neuropraxia, or damage to deeper structures of the face. Threads may extrude and may have to be trimmed or removed in the future. PDO Thread Lift is contraindicated in patients with cutaneous neurofibromatosis, excoriation disorders, allergy or foreign body sensitivities to plastic biomaterials, or existing implants in the area of treatment.

LASER SERVICES:

Laser therapy is not recommended if any of the following conditions exist: pregnancy, nursing, photosensitivity disorder, immunosuppressive disease, diabetes, bleeding disorder, seizure disorder triggered by light, active herpes, active shingles, or any active infection. I will notify my treating clinician if I have any of these conditions. Laser hair removal is not recommended for individuals who have used Accutane within the last six months or who used medications requiring limited exposure to sunlight.It should be understood that laser treatments may need to be repeated several times before complete satisfaction is achieved.  No guarantees have been made to me regarding the outcome of the treatment or any improvements in my condition due to the procedure.

Possible Risks:

  • Pain, burning, blister formation, and stinging sensation at the site of treatment.
  • Infection associated with the treatment site.
  • Pigmentary (color) changes at the treatment sites including a decrease in skin color (hypopigmentation or lightening) and/or increase in skin color (hyperpigmentation or darkening).
  • Scar formation at the treated site.
  • Laser-induced “cold sore like” blistering skin eruptions known as “herpetic” skin eruptions at the treatment site or surrounding tissue.
  • Poor cosmetic outcome.
  • Recurrence of vessels at the treated sites.

CONSENT FOR TREATMENT

Acceptance:

I acknowledge that I have read and fully understand the above consent to have all procedures and treatments performed

Date of Birth:

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