I certify that I am not pregnant and that I have no significant neurological disease, asthma, HIV, and/or facial herpes. Also, to the best of my knowledge, I certify that I have listed all allergies/sensitivities and that I am not allergic to eggs/egg products or lidocaine. *
I am aware that several treatments may be needed to attain the most desired results and that follow-up injections are inevitably necessary to maintain desirable results. The time frame varies for each patient, but generally speaking, each completed treatment lasts for approximately 3-4 months. I understand that improvement in the areas injected typically occurs within three to ten days. If satisfactory results are not achieved within that time frame, I understand that I can call to set up an appointment for re-injection/touch-up. Unless special arrangements have been made, there are charges for re-injection to cover the cost of materials.
I understand that side effects/complications are rare, but occasionally a headache, slight swelling and/or bruising may occur after treatment(s) for a few minutes to several days after injection(s).
Rarely, during a neuromodulator treatment, a muscle close to an injection site may be temporarily weakened for several weeks as a result of solution migration in the injected tissue. I have been advised of the risks involved with therapeutic injections and of the alternative treatments including no treatment at all.
Although results of these types of aesthetic dermatologic injections are usually dramatic and positive, I have been informed that it is not an exact science and that no guarantees can be made regarding expected results in my case. After multiple injections, it is also possible that your body may produce antibodies reducing the effectiveness of the treatment(s).
I understand that post-treatment instructions include avoidance of manipulation/vigorous rubbing of the treated areas as well as avoidance of vigorous physical activity for four hours post-treatment.
I agree that this form constitutes full disclosure and that it supersedes any related previous communication(s). All of my questions have been satisfactorily answered and I am prepared to undergo the designated injection treatment(s).
I consent to the taking of photographs, if needed, to document the change in my appearance. Such photos would be kept in my private file and would not be made public unless I sign a separate media release form.
Patient Name: *
