Botox®/Dysport®/Xeomin® therapy for wrinkles is an injection treatment designed to reduce facial expression lines. They all are approved by the FDA for the treatment of wrinkles in the glabellar area. When this therapy is performed, small amounts of toxin are injected into the facial muscles responsible for movement associated with lines and wrinkles. This injection weakens or paralyzes the muscle thus reducing the associated lines and wrinkles. The most common areas for this therapy is temporary, meaning it must be repeated on a regular basis to remain effective. The weakening effect gradually begins anywhere from 24 hours to 3 days, and is sometimes not complete for two weeks. During this period, you may notice asymmetry or unevenness within treated areas. This asymmetry will usually correct itself as the toxin takes effect. For maximal results, it is recommended that you maintain an upright posture for at least 4 hours. During this time, it is also recommended that the treated area not be rubbed vigorously or massaged. You may wish to actively move, by expression, the treated areas during this time as this may help to increase the response of the targeted muscles.
There are not known permanent side effects. There are, however, several possible side effects that are temporary which include:
Bruising: Occurs at or near the actual injection site. This effect clears within 7-10 days. No treatment is necessary.
Headache: Related to the actual injection, is usually mild and transient, lasting less than 24 hours. May be relieved with Tylenol.
Asymmetry: As described above, if present, will be noticed in the first two weeks of therapy. May be corrected with touch-up injections if necessary. There is typically a fee for touch-up injections.
Numbness: A change in sensation noticed by some patients in the treated area better described as dullness. It is usually only noticed for a few days after treatment.
Eyebrow or Eyelid ptosis (drooping) or diplopia (double vision): Seen in only 1-2% of patients receiving this therapy is temporary lasting weeks and usually mild.
Also for reasons not fully understood, some patients may be less sensitive or resistant to the effects of the toxins. Very deep creases may not be completely resolved with treatment.
I understand these procedures will not be performed during pregnancy or while nursing.
I authorize photographs to be taken which may be used for medical publications, lay publications, education, or during lectures. I understand that I will not be entitled to any payment because of any of these images.
Because this therapy for wrinkles is considered a cosmetic procedure, insurance does not pay for treatment. Payment at the time of service is required for all patients.
By signing below, I agree that I have read and understand the above information and that my questions have been fully answered to my satisfaction. I understand that the practice of medicine and surgery is not an exact science and that the results are not guaranteed. I also agree to be personally and fully responsible for any fees.
A. PURPOSE AND BACKGROUND: As my patient, you have requested my administration an HA dermal fillers. These are stabilized hyaluronic acids used in the correction of moderate to severe facial wrinkles and folds. All medical and cosmetic procedures carry risks and may cause complications. The purpose of this document is to make you aware of the nature of the procedure and its risks in advance so that you can decide whether to go forward with the procedure.
B. RISKS/DISCOMFORT
1. Although a very thin needle is used, common injection-related reactions could occur. These could include: some swelling, pain, itching, discoloration, bruising or tenderness at the injection site. You could experience temporary increased bruising or bleeding at the injection site if you are using substances that reduce blood clotting such as aspirin or other non-steroidal anti-inflammatory drugs such as Advil®.
2. As with all injections, this procedure carries the risk of infection. The syringe is sterile and standard precautions associated with injectable materials have been taken.
3. Some patients may experience additional swelling or tenderness at the injection site and in rare occasions, pustules might form. These reactions might last for as long as approximately 2 weeks, and in appropriate cases may need to be treated with oral corticosteroids or other therapy. Some visible lumps may occur temporarily following the injection.
4. None of the above-mentioned dermal fillers should be used in patients who have experienced: hypersensitivity, those with severe allergies or bacterial protein allergies, and should not be used in areas with active inflammation or infections (e.g., cysts, pimples, rashes, or hives). Dermal fillers should not be used in areas other than the tissues of the face.
5. People with a history of cold sores may experience a recurrence after the treatment, although this can be minimized using antiviral medicines. I agree to consult with my physician prior to this treatment if I have a history of cold sores or fever blisters/
6. Most patients are pleased with the results, however, like any cosmetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that wrinkles and folds will disappear completely, or that you will not require additional treatments to achieve the results you seek. While the effects of a dermal filler can last longer than other comparable treatments, the procedure is still temporary. Additional treatments will be required periodically, generally within 6 months to one year, involving additional injections for the effect to continue.
C. BENEFITS: Dermal fillers have been shown to be safe and effective when compared to collagen skin implants and related products to fill in wrinkles, lines, and folds in the skin on the face. Its effect, once the optimal location and pattern of cosmetic use is established, can last 6 months or longer without the need for re-administration.
D. COST/PAYMENT: The cost of treatment will be billed to you individually. Since most uses of dermal fillers are considered cosmetic, they are generally not reimbursable by government or private health care insurers.
E. CONSENT: Your consent and authorization for this procedure is strictly voluntary. By signing this informed consent form, you hereby grant authority to your physician to perform Facial Augmentation and Filler Therapy/Injections using any of the above mentioned dermal fillers and/or to administer any related treatment as may be deemed necessary or advisable in the diagnosis and treatment of your condition.
The nature and purpose of this procedure, with possible alternative methods of treatment as well as complications, have been fully explained to your satisfaction. No guarantee has been given by anyone as to the results that may be obtained by this treatment.
I have read this informed consent and certify that I understand its contents in full. I have had enough time to consider the information from my physician and feel that I am sufficiently advised to consent to this procedure. I hereby give me consent to this procedure and have been asked to sign this form after my discussion with the physician.
Notice of Privacy Practices Summary and Signature Page
In accordance with HIPAA federal regulations, this Practice will not disclose any information about you or your personal health without your permission. All information received while a patient and if/when you decline to be a patient no longer, will be kept confidential.
Patient Consent for Use and Disclosure of Protected Health Information
By signing this form, you consent to the use and disclosure of your protected health information by our staff, and our business associates strictly for the purchase of treatment, payment, and health care operations.
You acknowledge you have had an opportunity to review our Notice of Privacy Practices prior to signing this consent. We encourage you to review our Notice of Privacy Practices carefully. It provides more detail on how we may use and disclose of your information. The Notice of Privacy Practices may change. A current copy may be requested when you are being seen as a patient.
By signing this form, I grant my consent for the Practice to use and disclose my protected health information for the purposes of treatment, payment, and health care operations. I also acknowledge that I have read the Notice of Privacy Practices for Medical Bariatrics, PC., and confirm that I have had any questions answered and have a full understand of their privacy practices.
Authorization to Release Medical Information
If I am unable to be reached, or at my direction, I give permission for Medical Bariatrics, PC, to release any of my current medical information, including scheduling information, to the party listed below.
Δ
