Botox and Filler Consent form

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Date of Birth *

Current Medications: *

If none, type none.

Allergies: *

If none, type none.

Past surgeries: *

If none, type none.

Have you had botox or dermal fillers in the past? *

If yes, please list facility/provider name, botox/filler brand, & date

Have you taken aspirin, ibuprofen or fish oil in the last 2 weeks? *

Do you have any active skin diseases or infections? *

Have you ever been diagnosed with Myasthenia Gravis? *

Have you ever been diagnosed with amyotrophic lateral sclerosis (Lou Gehrig's Disease), or Lambert-Eaton syndrome? *

FEMALES: Are you pregnant or nursing?

Females: Are you pregnant or trying to become pregnant?

Are you interested in FDA-approved weight loss services? *

Yes, please contact me at my cell or email listed above (PLEASE CONFIRM YOU CONTACT)
No, but when I do, I have your contact info to reach out to you
Maybe, I'll think about it and let you know eventually

BOTULINUM TOXIN INFORMED CONSENT The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives of the procedure named above. This material serves as a supplement to the discussion you have with your doctor/healthcare provider. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing the consent form. THE TREATMENT: Botulinum toxin (Botox® and similar agents) is a neurotoxin produced by the bacterium Clostridium A. Botulinum toxin can relax the muscles on areas of the face and neck which cause wrinkles associated with facial expressions or facial pain. Treatment with botulinum toxin can cause your facial expression lines or wrinkles to be less noticeable or essentially disappear. Areas most frequently treated are: a) glabellar area of frown lines, located between the eyes; b) crow’s feet (lateral areas of the eyes); c) forehead wrinkles; d) radial lip lines (smokers lines), e) head and neck muscles. Botox is diluted to a very controlled solution and when injected into the muscles with a very thin needle, it is almost painless. Patients may feel a slight burning sensation while the solution is being injected. The procedure takes about 15-20 minutes and the results can last up to 3 months. With repeated treatments, the results may tend to last longer. RISKS AND COMPLICATIONS: Before undergoing this procedure, understanding the risks is essential. No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalization, and/or extended outpatient therapy to permit adequate treatment. 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: 1.Post treatment discomfort, swelling, redness, and bruising, 2. Double vision, 3. A weakened tear duct, 4. Post treatment bacterial, and/or fungal infection requiring further treatment, 5. Allergic reaction, 6. Minor temporary droop of eyelid(s) in approximately 2% of injections, this usually lasts 2-3 weeks, 7. Occasional numbness of the forehead lasting up to 2-3 weeks, 8. Transient headache and 9. Flu-like symptoms may occur. PREGNANCY, ALLERGIES & NEUROLOGIC DISEASE: I am not aware that I am pregnant and I am not trying to get pregnant, I am not lactating (nursing). I do not have any significant neurologic disease including but not limited to myasthenia gravis, multiple sclerosis, lambert-eaton syndrome, amyotrophic lateral sclerosis (ALS), and parkinson’s. I do not have any allergies to the toxin ingredients, or to human albumin. RIGHT TO DISCONTINUE TREATMENT: I understand that I have the right to discontinue treatment at any time. RESULTS: I am aware that when small amounts of purified botulinum toxin are injected into a muscle it causes weakness or paralysis of that muscle. This appears in 7 – 14 days and usually lasts up to 3 months but can be shorter or longer. In a very small number of individuals, the injection does not work as satisfactorily or for as long as usual and there are some individuals who do not respond at all. I understand that I will not be able to use the muscles injected as before while the injection is effective but that this will reverse after a period of months at which time re- treatment is appropriate. I understand that I must stay in the erect posture and that I must not manipulate the area (s) of the injections for the 2 hours post-injection period. Payment is due at the time services are rendered. According to FDA Policy Sec. 460.300, I acknowledge that I cannot return or receive refunds for medications and/or injections once the medications/injections leave the office regardless of effectiveness or possible adverse reactions. All service fees paid are FINAL. I understand this is an elective procedure and I hereby voluntarily consent to treatment with botulinum toxin injections for facial dynamic wrinkles. The procedure has been fully explained to me. I also understand that any treatment performed is between me and the doctor/healthcare provider who is treating me and I will direct all post-operative questions or concerns to the treating clinician. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure and I understand that no guarantees are implied as to the outcome of the procedure. I also certify that if I have any changes in my medical history I will notify the doctor/healthcare professional who treated me immediately. I also state that I read and write in English. *

Sign Here, write "No" for no consent to Botox injections

DERMAL FILLERS INFORMED CONSENT: The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives of the procedure named above. This material serves as a supplement to the discussion you have with your doctor/healthcare provider. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing the consent form: The Treatment: Hyaluronic acid, poly-L-lactic acid, or Calcium Hydroxylapatite treatments involve injection of purified Hyaluronic acid, poly-L-lactic acid, or Calcium Hydroxylapatite into the skin to fill wrinkles and restore volume. No skin testing is needed prior to treatment. Just like natural hyaluronic acid, poly-L-lactic acid, or Calcium Hydroxylapatite, injectable Hyaluronic acid, poly-L-lactic acid, or Calcium Hydroxylapatite eventually loses its form and wears down. While the effects of injectable Hyaluronic acid, poly-L-lactic acid, or Calcium Hydroxylapatite can last 6 months or longer, the procedure is still temporary. Ongoing treatments are required to maintain the improvements achieved with Hyaluronic acid, poly-L-lactic acid, or Calcium Hydroxylapatite . However, due to various factors that influence Hyaluronic acid Calcium Hydroxylapatite breakdown, no guarantees can be made regarding how long correction will last in a specific patient. Alternative Treatment to Hyaluronic acid treatments, poly-L-lactic acid, or Calcium Hydroxylapatite include, but are not limited to, other dermal fillers (e.g. collagen, fat, synthetic polymers), laser resurfacing, surgical facelift, lasers for skin laxity, or no treatment at all. Patients with the following conditions may not receive Hyaluronic acid, poly-L-lactic acid, or Calcium Hydroxylapatite treatments: previous allergic reactions to injectable Hyaluronic, poly-L-lactic acid, or Calcium Hydroxylapatite products, history of a serious allergic reaction (anaphylactic), multiple severe allergies, abnormal raised scarring or keloid formation, active inflammation or infection in the treatment area (e.g. pimples, herpes, rash, hives), pregnancy, or nursing. Certain conditions require caution with injectable fillers and may preclude a patient from receiving treatment: Poor healing (due to diabetes or other conditions) and long-term use of Prednisone or other steroid therapy. Recurrent viral infections such as herpes simplex (cold sores) may be activated by Hyaluronic, poly-L-lactic acid, or Calcium Hydroxylapatite treatments. The physician or nurse must be notified of these conditions prior to treatments. Risks The possible risks, side effects, and complications with Hyaluronic acid, poly-L-lactic acid, or Calcium Hydroxylapatite treatment include, but are not limited to: Pain and tenderness during and after treatments at/around the treated site which typically resolves within a few days to a week. Redness and swelling at/around the injection site is common. Itchiness may also occur. These reactions are generally present immediately after treatment and lesson or disappear within a few days to 1 week. Some patients may experience prolonged swelling and/or tenderness or pain at the injection site lasting up to 2 weeks. On rare occasions pustules (acne-like lesions) may form. The physician or nurse must be notified if symptoms persist for more than 1 week, if pustules are present, or symptoms appear in a delayed fashion after the treatment. Bruising usually resolves within 3-4 days after the injection. Patients taking medications that interfere with coagulation (e.g. aspirin, ibuprofen, Vitamin E, Fish Oil, alcohol) have an increased risk of bruising and bleeding. Infection at the treated site from poor hygiene. I have read and understand the above risks. Please read the following carefully. Although extremely rare, local tissue damage can occur with skin breakdown, scab formation, and/or scarring in the treated area. Visible raised areas and lumpiness at/around the treated site, grayish discoloration of the skin. These symptoms may persist from a few weeks to several weeks (rarely). Failure to reduce a contour defect or wrinkle (under correction) or overcorrection. Placement of filler adjacent to or outside of the desired treatment area; undesired changes in facial contour. Asymmetry, where the correction of one side may be different from the correction on the other side of the face. Swelling at the time of injection may create the appearance of asymmetry or under correction, which usually resolves as described above. However, you may need to return for additional treatment if under correction or asymmetry persists. Hyaluronic acid, poly-L-lactic acid, or Calcium Hydroxylapatite may have an unpredictable duration of action and may not last as long as anticipated or may persist in some areas longer than anticipated. A remote and rare risk is that of injecting Hyaluronic acid, poly-L-lactic acid, or Calcium Hydroxylapatite into a blood vessel, which can block flow in the treated area or in distant areas causing tissue damage. All the risks of Hyaluronic acid, poly-L-lactic acid, or Calcium Hydroxylapatite may not be known. The provider is not responsible for any Hyaluronic acid, poly-L-lactic acid, or Calcium Hydroxylapatite risk or unforeseen complication not yet discovered or not commonly known. I have read and understand the above. *

Sign Here, write "NO" for no consent to electronic communications

Patient Electronic Communications Consent Form: for BOTOX & DERMAL FILLERS Electronic communication is a widely accepted form of communication. While it cannot replace personal encounters between you and your health care provider, it can be a convenient way to exchange information. All electronic communication will be acknowledged in a timely fashion. However, we do not monitor when the office is closed for weekends, evenings, statutory holidays and vacations. Please consider our office hours when you are waiting for a reply to your electronic communication. As a general rule, we will respond to patient emails within 3 business days. If you do not receive a response within the designated time period, please assume that your email was not received and call the office to follow up. If you are experiencing a medical emergency PHONE 911 IMMEDIATELY. Acknowledgement and Consent. I understand and agree that: Electronic communication is not an appropriate substitute for clinical examinations. I am responsible for following up on the physician’s electronic communication and for scheduling appointments where warranted. Electronic communication is not to be used in emergencies, or when I need information or advice urgently. Electronic communication may be accessed by medical office staff in the course of their duties. Electronic communication may be accessed by my health care provider’s medical colleagues while caring for me when my health care provider is absent. Electronic communication will use respectful language . I will send pictures via electronic communication when I have been asked by my physician to do so. Electronic communication will not be used for frivolous or commercial purposes. Or any purpose outside the context of my direct patient-health care provider relationship, unless I give written or typed consent for my pictures to be used. Electronic communication between me and this medical practice will become part of my confidential patient record. This medical practice may use electronic communication to send me my photos and my treatment results. Electronic communication is a privilege that may be withdrawn at the discretion of this medical practice. Electronic communication can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the physician or patient. Electronic communication senders can easily misaddress an email, resulting in it being sent to unintended and unknown recipients. Electronic communication is indelible. Even after the sender and recipient have deleted their copies of the email, backup copies may exist on a computer or cyberspace. Use of electronic communication to discuss sensitive information can increase the risk of such information being disclosed to third parties. Emails and digital photos may be forwarded internally to staff and to those involved, as necessary, for diagnosis, treatment, reimbursement, or health care operations. Elevation Medical is not responsible for information loss due to technical failures. I will do my best to notify Elevation Medical of any changes to my electronic communication address.

Sign Here, write "NO" for no consent to electronic communications

Consent for Treatment with Hyaluronidase & Lidocaine Nerve Block for Dermal Fillers: Hyaluronic acid (HA) fillers are sterile gels consisting of non-animal stabilized hyaluronic acid for injection into the skin to correct facial lines, wrinkles and folds, for lip enhancement and for shaping facial contours. Occasionally these fillers need to be dissolved when the aesthetic treatment has not produced the desired outcome or there is a possibility of vascular occlusion or impending necrosis (tissue death) which could lead to compromise of healthy tissue. Hyaluronidase is an enzyme which breaks down hyaluronic acid fillers, but it can also break down naturally occurring hyaluronic acid present in the body, the results can be unpredictable. I understand that there will be loss of volume and there can be some skin laxity which in itself may not provide a good aesthetic result. Although some of the effects can be immediate, I understand it can take up to 24-48 hours for results to be seen and the treatment may need to be repeated. I will get emergency medical help if I have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Less serious side effects may include pain, itching, redness, or swelling where the medication was injected. This is not a complete list of side effects and others may occur. I have disclosed all my medical history and medications to my provider. I am currently not taking any of the following medications. 1) Furosemide (Lasix) 2) Phenytoin (Dilantin) 3) A sedative or anxiety medication (such as Valium, Xanax) 4) Aspirin or salicylates 5) Cortisone or ACTH (Corticotropin) 6) Estrogens 7) An antihistamine (such as a cold or allergy medicine) The use of and the indications for the administration of hyaluronidase have been explained to me by my practitioner and I have had the opportunity to have all questions answered to my satisfaction. After the treatment some other common injection-related reactions might occur. These reactions may include redness, swelling, pain, itching, bruising and tenderness at the injection site. They have generally been described as mild to moderate and typically resolve spontaneously a few days after injection. I acknowledge that I will have to remain at the clinic for thirty minutes after the procedure so that I can be observed by the practitioner and that I may need to return to the clinic in 1-2 weeks after treatment to assess if further hyaluronidase is to be administered. I have answered the questions regarding my medical history to the best of my knowledge. I have also received the aftercare information and its contents have been explained to me and I will follow the advice given. I consent to the administration of hyaluronidase. I am satisfied with the explanation. I have no known allergies to lidocaine and I have no known allergies to any anesthetics. *

Sign Here, write "NO" for no consent to treatment

Date of Birth *

Patient Consent for Dermal Fillers Treatment and Lidocaine Nerve Block: DERMAL FILLERS: Restylane -L, Restylane Silk, Restylane LYFT, Radiesse, Juvederm Ultra XC, Juvederm Ultra Plus XC, Juvederm Voluma XC, Juvederm Volbella, XC, Juvederm Vollure XC, Belotero, Sculptra, Indications: The dermal fillers above are sterile inject-able material consisting mainly of: Hyaluronic acids, or Hydroxyapatite molecules with or without lidocaine (numbing solution); These are non-permanent, and metabolized by the body. Filler injections are given to temporarily correct facial wrinkles, lines, folds, or scars, &/or for lip augmentation, &/or for replacement of volume to the face, cheeks, orbital rims, nose, temples, etc. Some of the fillers above have been approved by the FDA (Food and Drug Administration) for correction of facial wrinkles or lines, or for lip augmentation or for cheek augmentation (“on-label” use). Most fillers however, are also used “off-label” for the lips, eyelids, nose, cheeks, temples or other facial cosmetic corrections. I understand that the safety and effectiveness of treating facial areas “off label” has not been studied; however, fillers have been extensively used in all areas of the face depending on the filler and the technique. This “off-label” aspect of the treatment has been explained to me. Alternatives: There are alternatives to the specific filler injections above, including no treatment, collagen or fat injections, or other facial soft tissue augmentation or implants, as well as cosmetics, Botox, laser skin resurfacing, chemical peels, or plastic surgery for wrinkle reduction. Results: I understand that the actual degree of improvement cannot be predicted or guaranteed. Furthermore, I understand that the effect will gradually wear off and additional treatments are necessary to maintain the desired effect. Results depend on the filler as well as the amount or volume of the filler. Using multiple syringes often results in more dramatic improvement of wrinkles. I understand that I am responsible for the cost of each filler syringe and treatment without any guarantee of results. Side effects and complications include but are not limited to: • Potential allergic reaction. As with any product, allergies can develop during or after injection. Patients with known allergy to these fillers or certain food allergies or numbing medications should avoid these injections. • Injection site reactions: a lumpy or “thick” feeling at or just under the skin, bruising, hematoma, redness, discoloration, induration, scars, vascular occlusion, itching, pain, nerve damage, infection, over-correction, granulomas, palpable or visible material, blindness, tenderness, swelling, asymmetry, or shifting can occur. • Injections into the lip area could trigger a recurrence of facial cold sores (Herpes simplex infections) for patients with a history of prior cold sores. • Further treatment for additional improvement, or correction of side effects or complications may be necessary. I understand I am responsible for all such costs. • I understand that the majority of humans have facial asymmetry and therefore perfect symmetry is unrealistic in most cases. *Precautions and contraindications: • Due to the potential for an allergic reaction, fillers are not recommended for patients with severe allergies or a history of anaphylaxis to components of the particular filler. • The risk of bruising or bleeding may be increased by medications with anticoagulant effects, such as aspirin and nonsteroidal anti-inflammatory drugs (e.g., Ibuprofen, Aleve, Motrin, Celebrex), high doses of Vitamin E, and certain herbal supplements and foods (Ginkgo Biloba, St. John’s Wort, Flaxseed, nuts, fish oil, Omega-3, etc). • The safety of fillers in pregnant or breast-feeding women has not been established, and is therefore not recommended for these women. *Consent: I understand the possible need for local anesthesia to reduce the discomfort of the procedure and I consent to the topical application of anesthetic gel and/or injections of anesthetic for a nerve block or local infiltrative anesthesia with lidocaine. I understand the above, and have had the risks, benefits, and alternatives explained to me, and have had the opportunity to ask questions and refuse treatment. I have chosen this treatment voluntarily and no guarantees about results have been made. Further treatments may be needed. Payments are non-refundable. To the best of my knowledge, I have no known allergies to lidocaine or any anesthetics. I am not pregnant and/or breastfeeding. I give my informed consent for fillers injections today as well as future treatments as needed by Elevation Medical Weight Loss. This consent is valid indefinitely unless revoked in writing. *

Sign here, write "No" for no consent to Lidocaine Nerve Block

Are you interested in sildenafil (Viagra) 100mg tablets (2 doses) or tadalafil (Cialis) 5mg or 10 mg tablets for increased exercise performance, recovery, and help with Blood Pressure problems? *

Yes, please charge my card $75 for 10 tabs of sildanafil (20 doses total) and send it to my address if I qualify for this treatment
Yes, please charge my card $70 for 30 tabs of tadalafil (30 doses total; take 1 tab daily by mouth every morning with or without food) and send it to my address if I qualify for this treatment
Yes, please charge my card $100 for 15 tabs of tadalafil (30 doses total; take 1/2 (half) tab daily by mouth every morning with or without food) and send it to my address if I qualify for this treatment
No, I am not interested. But I am OK if you ask me again in the near future.
Other/Comments/Suggestions/Notes to Us

sildenafil (Viagra) and tadalafil (Cialis) are used in both men and women. These two blood pressure agents are known as anti-hypertensive medications, help improve blood circulation, increase airflow and overall breathing through targeting specific receptors in the heart and lungs. These medications are used to prolong lifespan, improve long-term happiness, treat depression, and allow patients to feel better. DO NOT TAKE sildenafil (Viagra) and tadalafil (Cialis) if you are currently taking any nitrates medications. However, sildenafil (Viagra) and tadalafil (Cialis) are safe to used during pregnancy and/or breastfeeding.

Are you interested in prescription-only ketoconazole 2% shampoo to help prevent hair loss, reduce hair loss, and to increase hair growth rate to have longer, thicker, and healthier hair? This is for both men and women, and safe to use during breastfeeding or pregnancy. *

Yes, please charge my card $99 for 2 refills (3 bottles total) of ketoconazole 2% shampoo (apply topically to the affected area once daily, wait 5 minutes, and wash off with warm water) and send it to my address if I qualify for this treatment. I will put my credit card information, cc expiration date, CVV number, my name and shipping address below to receive this medication at my house in the next 7-10 business days.
Yes, please charge my card $169 for 5 refills (6 bottles total) of ketoconazole 2% shampoo (apply topically to the affected area once daily, wait 5 minutes, and wash off with warm water) and send it to my address if I qualify for this treatment. I will put my credit card information, cc expiration date, CVV number, my name and shipping address below to receive this medication at my house in the next 7-10 business days.
Yes, please charge my card $299 for 11 refills (6 bottles total) of ketoconazole 2% shampoo (apply topically to the affected area once daily, wait 5 minutes, and wash off with warm water) and send it to my address if I qualify for this treatment. I will put my credit card information, cc expiration date, CVV number, my name and shipping address below to receive this medication at my house in the next 7-10 business days.
No, I am not interested. You may ask me again some other time.
Other/Comments/Suggestions/Notes to Us

I authorize appropriate charges to my credit card information for medical services after a physician's professional consultation either rin person or virtually through telehealth.

File Upload: Please take a photo of your Driver License or valid photo ID and attach here *

Click or drag a file to this area to upload.

Please send us your photo ID, valid driver license, and/or your credit card information to authorize consent to treat, verify your identity, and to render payments with your written permission.

Date / Time

Date

Time

Multiple Items *

I hereby authorize a charge of $99 or less in my provided credit card below for medical services rendered. I will receive a copy of my receipt either via snail-mail USPS or by email. - $ 99.00
I hereby authorize a charge of $99 or less in my provided credit card below for medical services rendered. I will receive a copy of my receipt either via snail-mail USPS or by email. - $ 350.00
I hereby authorize a charge of $500 or less in my provided credit card below for medical services rendered. I will receive a copy of my receipt either via snail-mail USPS or by email. - $ 500.00
I hereby authorize a charge of $1200 or less in my provided credit card below for medical services rendered. I will receive a copy of my receipt either via snail-mail USPS or by email. - $ 1,200.00

Name on Credit Card or CareCredit *

type "no" if non-applicable.

Credit Card Number or CareCredit # *

Credit Card Expiration Date and CVV *

Any Comments/Suggestions/Notes

Name

Updated 8/16/2020