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FACIAL INJURY TRAUMA HISTORY
I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to inform the practitioner or other health professional of my current medical health conditions and to update this history. A current medical history is essential for the practitioner to execute appropriate treatment procedures.
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INFORMED CONSENT FOR BOTULINUM TOXIN TREATMENT
THE TREATMENT
Botulinum toxin, Botox®, Dysport®, Xeomin® are neurotoxins 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) globellar 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, to human albumin or eggs.
ALTERNATIVE PROCEDURES
Alternatives to the procedures and options that I have volunteered for have been fully explained to me.
PAYMENT
I understand that this is an “elective” procedure and that payment is my responsibility and is expected at the time of treatment.
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 2-10 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 wil 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 4 hours post-injection period. I understand this is an elective procedure and I hereby voluntarily consent to treatment with botulinum toxin injections for facial dynamic wrinkles, TMJ dysfunction, bruxism and types of orofacial pain, including headaches and migraines. 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 to the outcome of the procedure. I also certify that if I have any changes in my medical history I will notify the practitioner/healthcare professional who treated me immediately. I also state that I read and write in English.
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I am the treating practitioner, I discussed the above risks, benefits, and alternatives with the patient. The patient had an opportunity to have all questions answered and was offered a copy of this formed consent. The patient has been told to contact my office should they have any questions or concerns after this treatment procedure.
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Photographic Release
I Hereby give my consent The Practitioner / Technician to take photos or Videos Before / During & Afterwards of any treatments, which maybe used only for promotional purposes on the company's social media & website.
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Data Protection and Privacy
We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.
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Appointment Guidance
- Please only attend at your appointment time
- Please ensure you are on time - if you are late this may result in your appointment being cancelled
- Please attend your appointment unaccompanied
- Please limit the personal possessions you bring with you
- Hand sanitiser will be provided upon arrival and will be available throughout your appointment
- Please wear a face covering to enter and walk around the salon/clinic
- We encourage contactless/card payments where possible
- If you experience Covid-19 symptoms after your appointment please contact us immediately
Please DO NOT attend your appointment. Please contact us to cancel / reschedule.
Please DO NOT attend your appointment. Please contact us to cancel / reschedule.