- Botox Consent Form
To the Patient
Being fully informed about your Botulinum Toxin Type A treatment (“Treatment”) will help you make the decision whether to undergo the Treatment. This disclosure is not meant to alarm you; it is simply an effort to better educate and inform you so that you may give or withhold your consent for this Treatment.
Botulinum Toxin Type A treatments are an FDA-approved treatment for the temporary improvement in the appearance of moderate to severe forehead lines, frown lines, and crow’s feet in adult patients. I understand that this Treatment is completely voluntary and that the results may be unpredictable. Results vary from person to person and may even in vary in different areas on the same person. Multiple Treatments are necessary to achieve desired results and the number of Treatments recommended during my consultation is only an estimate. I also understand that the Treatment is in most cases effective, but there is no guarantee that the expected or anticipated results will be achieved.
Alternative forms of management include not treating the skin wrinkles by any means. Improvement of skin wrinkles may be accomplished by other treatments or alternative types of surgery such as a blepharoplasty, face or brow lift when indicated. Other forms of eyelid surgery may be needed should you have intrinsic disorders affecting the function of the eyelid such as drooping eyelids from muscle problems (eyelid ptosis) or looseness between the eyelid and eye (ectropion). Minor skin wrinkling may be improved through chemical skin-peels, lasers, injection of filling material, or other skin treatments. Risks and potential complications are associated with alternative forms of medical or surgical treatment.
No Guaranties Promised
I acknowledge that aesthetic treatments are not an exact science, and no specific guaranties can or have been made concerning the outcome. I understand that some clients experience more change and improvement than others. In virtually all cases, multiple treatments are required to realize a difference and maintain the results.
You should not have cosmetic injectables if: you are pregnant; nursing; allergic to albumin; have an infection, skin condition, or muscle weakness at the site of the injection; or have Eaton-Lambert syndrome, Lou Gehrig’s disease, myasthenia gravis, peripheral motor neuropathic disorders or taking aminoglycoside antibiotics or other drugs known to interfere with neuromuscular transmission. I have requested that Allure Med Spas service provider treat my facial lines and enhance facial shaping with Botulinum Toxin Type A. These injections have been used for nearly two decades to improve spasms of the muscles around the eye, to correct double vision due to muscle imbalance as well as numerous other neurological uses. Botulinum Toxin Type A are approved by the FDA to improve the appearance of the vertical lines between the brows. Injections in other areas to improve appearance of facial lines and for facial shaping have been well documented, although are considered “off label” uses.
Consent to Anesthetics
I consent to the administration of such anesthetics considered necessary or advisable. I understand that all forms of anesthesia involve risk and the possibility of complications, injury, and sometimes death.
For Cosmetic Purposes Only
I understand that I am having Botulinum Toxin Type A Cosmetic injections for cosmetic purposes only. These injections are not being used to treat headaches, spasticity, eye disorders, or any other medical conditions. No suggestion of benefit of Botulinum Toxin Type A Cosmetic injections for any medical conditions has been made.
The Botulinum Toxin Type A solution is injected with a tiny needle into the muscle; you should see the benefits develop over the next two to seven days. A decreased appearance of frowning or creasing of other lines may be the result of this treatment. As with any injections, slight pain will likely accompany injections with Botulinum Toxin Type A.
Adverse Side Effects
The most common side effects are headache, respiratory infection, flu syndrome, temporary eyelid droop, and nausea. Eyelid drooping may lead to dry eyes and eye drops may be required to be instilled into the eyes until the problem resolves. This resolution may take weeks to months. Double vision may occur after Botulinum Toxin Type A Cosmetic injections but is very rare. Infection and allergic reaction are also rare side effects of Botulinum Toxin Type A Cosmetic injections. Additionally, slight temporary bruising may occur at the injection site. There are the possibility additional risk factors may be discovered. Botulinum Toxin Type A Cosmetic should not be used if there is an infection at the injection site.
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: Bleeding and Bruising – It is possible, though unusual, to have a bleeding episode from a Botulinum Toxin Type A Cosmetic injection. Bruising in soft tissues may occur. Serious bleeding around the eyeball during deeper Botulinum Toxin Type A Cosmetic injections for crossed eyes (strabismus) has occurred. Should you develop post-injection bleeding, it may require emergency treatment or surgery. Aspirin, anti-inflammatory medications, platelet inhibitors, anticoagulants, Vitamin E, ginkgo biloba, and other “herbs / homeopathic remedies” may contribute to a greater risk of a bleeding problem. Do not take these for ten days before or after Botulinum Toxin Type A Cosmetic injections. Damage to Deeper Structures – Deeper structures such as nerves, blood vessels, and the eyeball may be damaged during injection. Injury to deeper structures may be temporary or permanent. Corneal Exposure Problems – Some patients experience difficulties closing their eyelids after Botulinum Toxin Type A Cosmetic injections and problems may occur in the cornea due to dryness. Should this rare complication occur, additional treatments, protective eye drops, contact lenses, or surgery may be necessary. Dry Eye Problems – Individuals who normally have dry eyes may be advised to use special caution in considering Botulinum Toxin Type A Cosmetic injections around the eyelid region. Migration of Botulinum Toxin Type A – Botulinum Toxin Type A may migrate from its original injection site to other areas and produce temporary paralysis of other muscle groups or other unintended effects. Botulinum Toxin Type A has been reported to cause swallowing problems in patients treated for spastic muscle disorders of the cervical region (cervical dystonia). Drooping Eyelid (Ptosis) – Muscles that raise the eyelid may be affected by Botulinum Toxin Type A, should this material migrate downward from other injection areas. Double-Vision – Double-vision may be produced if the Botulinum Toxin Type A material migrates into the region of muscles that control movements of the eyeball. Eyelid Ectropion – Abnormal looseness of the lower eyelid can occur following Botulinum Toxin Type A Cosmetic injection. Other Eye Disorders – Functional and irritative disorders of eye structures may rarely occur following Botulinum Toxin Type A Cosmetic injections. Blindness – Blindness is extremely rare after Botulinum Toxin Type A Cosmetic injections. However, it can be caused by internal bleeding around the eyeball or needle stick injury. In a period of 10 years of Botulinum Toxin Type A administration, complications of blurred vision, retinal vein occlusion, and glaucoma have been reported in three patients. The occurrence of eye problems appears to be very rare. Asymmetry – The human face and eyelid region is normally asymmetrical with respect to structural anatomy and function. There can be a variation from one side to the other in terms of the response to Botulinum Toxin Type A Cosmetic injection. Pain – Discomfort associated with Botulinum Toxin Type A Cosmetic injections is usually short duration. Allergic Reactions – As with all biologic products, allergic and systemic anaphylactic reactions may occur. Allergic reactions may require additional treatment. Antibodies to Botulinum Toxin Type A presence of antibodies to Botulinum Toxin Type A cosmetic injections may reduce the effectiveness of this material in subsequent injections. The health significance of antibodies to Botulinum Toxin Type A Cosmetic injections is unknown. Infection – Infection is extremely rare after Botulinum Toxin Type A cosmetic injection. Should an infection occur, additional treatment including antibiotics may be necessary. Skin Disorders – Skin rash, itching, and swelling may rarely occur following Botulinum Toxin Type A cosmetic injection. Neuromuscular Disorders – Patients with peripheral motor neuropathic disorders (amyotrophic lateral sclerosis, myasthenia gravis, motor neuropathies) may be at greater risk of clinically significant side effects from Botulinum Toxin Type A Cosmetic injections. Migraine Headache Disorders – Botulinum Toxin Type A Cosmetic injections has been used to treat forehead muscle groups that are involved with the migraine headache condition. Patients are advised that results of Botulinum Toxin Type A treatment for migraine headaches may be variable and improvement in this disorder may not occur following Botulinum Toxin Type A treatments. Unsatisfactory Result – There is the possibility of a poor or inadequate response from Botulinum Toxin Type A Cosmetic injections. Additional Botulinum Toxin Type A Cosmetic injections may be necessary. Surgical procedures or treatments may be needed to improve skin wrinkles including those caused by muscle activity. Long-Term Effects – Subsequent alterations in face and eyelid appearance may occur as the result of aging, weight loss, weight gain, sun exposure, pregnancy, menopause, or other circumstances not related to Botulinum Toxin Type A Cosmetic injections. Botulinum Toxin Type A Cosmetic injection does not arrest the aging process or produce permanent tightening of the eyelid region. Future surgery or other treatments may be necessary. Pregnancy and Nursing Mothers – Animal reproduction studies have not been performed to determine if Botulinum Toxin Type A Cosmetic injections could produce fetal harm. It is not known if Botulinum Toxin Type A Cosmetic injections can be excreted in human milk. It is not recommended that pregnant women or nursing mothers receive Botulinum Toxin Type A Cosmetic treatments. Drug Interactions – The effect of Botulinum Toxin Type A Cosmetic injections may be potentiated by aminoglycoside antibiotics or other drugs known to interfere with neuromuscular transmission. Unknown Risks – The long-term effect of Botulinum Toxin Type A on tissue is unknown. The risk and consequences of accidental intravascular injection of Botulinum Toxin Type A is unknown and not predictable. There is the possibility of additional risk factors may be discovered. Other Risks – Reactivation of herpes (cold sores); Lumpiness, visible yellow or white patches; Granuloma formation; Localized necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occurs.
Advisement of Risks
I have been advised of the risks involved in such treatment, the expected benefits of such treatment, and alternative treatments, including no treatment at all.
Seek Emergency Care
While effects beyond the local area being injected are extremely unlikely, they are not impossible. If I have trouble swallowing, talking, or breathing, or have slurred speech or muscle weakness I will seek emergency medical care immediately.
Results Not Guaranteed
The results of Botulinum Toxin Type A Cosmetic injections are usually dramatic, although the practice of medicine is not an exact science, and no guarantees can be or have been made concerning expected results.
Results are Temporary
I understand that the results are temporary, and several sessions may be needed for optimal results. The duration of effect generally lasts for approximately three to four months. Continuing treatments are necessary to maintain the effect of Botulinum Toxin Type A over time. No guarantee has been made as to the outcome of my being treated with Botulinum Toxin Type A, and I understand that the results may not be satisfactory to me.
Agreement to Follow Pre and Post Care Instructions
I have read and understand the Pre- and Post-Treatment Instructions. I agree to follow these instructions carefully. I understand that compliance with recommended pre and post procedure guidelines are crucial for healing, prevention of side effects and complications. I understand pre‐care and after‐care is entirely in my control and that my failure to follow the provided pre‐care and after‐care guidelines will increase the chance of complications and adverse side effects and decrease the effectiveness of the Treatment. I acknowledge that I have been (or will be given) detailed oral and printed care instructions along with a contact phone number if I have any questions about pre‐care or after‐care. I agree to follow all the pre‐care and after‐care instructions provided to me.
I have fully disclosed on my client intake form any medications, previous complications, or current conditions that may affect my treatment.
Consent to Photograph/Record
I consent to the photographing of the procedure(s) to be performed, including appropriate portions of my face, for medical, scientific, or educational purposes.
Pre and Post Treatment
BOTULINUM TOXIN TYPE A PRETREATMENT TIPS Eat Breakfast The morning of, consume plenty of food and drink as this will decrease the chances of lightheadedness during the treatment. Remove Makeup If you wear makeup to your appointment, we’ll need to remove it before your treatment in order to get a clean canvas. Workout Before Treatment Be sure to have your daily workout before your treatment, since we don’t recommend any exercise for 24 hours afterwards. Limited Downtime You can get right back to work after your treatment, but we recommend leaving yourself an hour of time to avoid being stressed or rushed. Pregnancy & Breastfeeding You are not a candidate for these injections if you are pregnant or breastfeeding. No Wine One Week Prior Drinking red wine can increase your chances of bruising following Botulinum Toxin Type A. To avoid this, patients should plan to give up wine for seven days before they come for treatment. Don’t Take Anti-Inflammatories Week Prior Ideally, you will be able to enjoy the results of your Botulinum Toxin Type A treatment within 4-5 days: less prominent facial lines and overall younger-looking features. However, bruising and discoloration aren’t part of anyone’s plan for aesthetic improvement. That’s why we recommend that you avoid anti-inflammatory medications for seven days before you have Botulinum Toxin Type A injections. There are certain patients for whom anti-inflammatory medications are medically necessary. If this is your case, please discuss this need during your initial consultation so that we can plan your care accordingly. Avoid Foods Containing Garlic Eating garlic can increase your chances of bruising after Botulinum Toxin Type A. Patients should not consume food with garlic for seven days before their procedure. While giving up garlic and other recommendations to this point have focused on what to avoid, there’s one remedy that we suggest Botulinum Toxin Type A patients add to their routine. We advise patients to begin using arnica, a natural herb, to minimize bruising prior to the Botulinum Toxin Type A treatment. BOTULINUM TOXIN TYPE A POST TREATMENT TIPS Delay Workouts We recommend either workout before the Botulinum Toxin Type A treatment or wait until at least the morning after the treatment to resume your normal workout pattern. Exercise can raise a patient’s blood pressure and increase the risk of inflammation. Delay Makeup We recommend that you not use makeup for one day after your visit. Makeup and other foreign substances on the skin can interact with Botulinum Toxin Type A injection sites, and this can lead to an infection that causes redness, swelling, and discomfort. Use Gentle Face Cleanser The right hygienic regimen can keep your skin healthy and beautiful. However, you may be using an aggressive facial cleanser, which can cause an infection after Botulinum Toxin Type A injections. We can advise you about alternative cleansers if necessary. You can return to your normal hygienic routine 24 hours after your procedure. No Facials or Massage Avoid facials and facial muscle manipulation for two weeks after treatment. Avoid Lying Down Avoid lying down or yoga poses such as downward dog for 4 hours after your procedure. This is to avoid the risk of pressure on the treated areas and to avoid the risk of having the area rubbed accidentally. Take Arnica Take an arnica tablet every six hours after your injections, for the next several days. Avoid painkillers. Painkillers should be used sparingly for headaches or facial pain. Strong painkillers such as Aspirin and ibuprofen should be avoided.
Right to Discontinue
I understand that I have the right to discontinue treatment at any time.
Customer Agrees to Instructions and Requirements I will follow all the instructions of Allure Med Spas Inc. while on the Premises. I agree not to enter the Premises if I am experiencing symptoms of COVID-19 such as cough, shortness of breath, or fever, have a confirmed or suspected case of COVID-19, or have come in contact in the last 14 days with a person who has been confirmed or suspected of having COVID-19. Customer Assumes the Risk I am aware of the highly contagious nature of COVID-19 and the risk that I may be exposed to or contract COVID-19 by being on the Premises and engaging in the Activity. I acknowledge that I am voluntarily entering the Premises to engage in the Activity with knowledge of the danger involved. I hereby agree to accept and assume all risks of personal injury, illness, disability, or death related to COVID-19, arising from my being on the Premises or engaging in the Activity, whether caused by negligence of Allure Med Spas Inc. or otherwise. Customer Releases Allure Med Spas Inc. from Liability I hereby expressly waive and release any and all claims, now known or hereafter known, against Allure Med Spas Inc. and its owners, employees, affiliates, and officers, on account of injury, illness, disability, or death arising out of or attributable to my being on the Premises or engaging in the Activity and being exposed to or contracting COVID-19, whether arising out of the negligence of Allure Med Spas Inc., its owners, employees, affiliates, officers, or otherwise.
We understand that sometimes a patient is unable to make a scheduled appointment due to unforeseen circumstances. However, we require patients to reschedule or cancel appointments within 24 hours of a scheduled visit. If you are a no show or fail to reschedule/cancel an appointment without giving the 24 hours’ notice a $50.00 charge will be applied to the card on file for each missed appointment. Missing an appointment prevents us from scheduling another patient during the reserved appointment time.
Credit Card Authorization Agreement
I authorize Allure Med Spas Inc. to keep my credit card on file for any future transactions until I request a cancellation. I understand that the terms of this authorization will remain in effect until I request that they be terminated. I acknowledge that I am responsible for making this request in writing.
Our Pledge Regarding Medical Information We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. This Notice applies to all records of your care generated and maintained by Allure Med Spas Inc. We are required by law to 1) make sure that medical information that identifies you is kept private; 2) make available to you this Notice of our legal and privacy practices with respect to medical information about you; and 3) follow the terms of the Notice that is currently in effect. How We May Use and Disclose Medical Information About You • We may disclose medical information about you to doctors, nurses, or other personnel involved in taking care of you. We may also disclose medical information to people outside Allure Med Spas Inc., such as family members, specialists or others who are involved in providing services that are part of your care. • We may use or disclose medical information about you for Allure Med Spas Inc. operations. These may include use of information to evaluate the performance of our staff, effectiveness of programs, and ways to improve care and services we offer. These uses, and disclosures are necessary to ensure that all our clients receive quality care. • We may use or disclose medical information to tell you about or recommend possible treatment options or alternatives, and about health-related benefits, services, events, and activities that may be of interest to you. • We may disclose medical information about you to other healthcare providers in the event you need emergency care. • We may disclose medical information to a public health organization or federal organization when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. • Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written authorization. You may later revoke this permission in writing at any time. Your Rights Regarding Your Medical Information • You have the right to review and receive a copy of medical information that may be used to make decisions about your care. Usually this includes medical and billing records. You must submit a written request to review and copy your medical information. There may be a fee to supply the copies. • You have the right to ask us to amend medical information that you feel is incorrect or incomplete. Your request for an amendment must be in writing and must provide a reason that supports your request. We may deny your request if: 1) it is not supplied in writing with a reason 2) was not created by us 3) not part of the medical record kept by us or for us 4) isn’t part of the information you are permitted to inspect and copy or 5) is accurate and complete. • You have the right to request an “accounting of disclosures”. These exceptions are governed by federal health policy law, and include: 1) routine disclosures for treatment, payment & operations conducted pursuant to your signed consent form 2) disclosures to you. You must submit a written request. The request must state a time period that may not be longer than 6 years and may not include dates before April 14, 2003, when federal health privacy laws became effective. • You have the right to request restrictions or limitations on the use or disclosure of medical information about you. You must submit a written request for restriction that specifies: 1) what information you want to limit 2) whether you want to limit our use, disclosure or both 3) to whom you want the limits to apply. We reserve the right to refuse your restriction if it conflicts with providing you quality healthcare or in an emergency. • You have the right to request that we communicate with you about medical matters in a certain way or at a certain location, such as only at work or by mail. You must submit a written request for confidential communications restrictions, specifying how or where you wish to be contacted. • You have the right to possess a copy of this Privacy Notice upon request. • You have the right to file a complaint if you believe your rights to privacy have been violated. All complaints must be submitted in writing. All complaints will be investigated. No personal issue will be raised for filing a complaint.
It is understood that any dispute as to Allure Med Spas Inc. treatments, that is, as to whether any services rendered under this contact were unauthorized or were improperly, negligently or incompetently rendered will be determined by submission to arbitration as provided by state law, and not by a lawsuit or court process, except as therein constitutional rights to have any such dispute decided in a court of law before a jury, and instead are accepting the use of the arbitration. It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or service provided by provider including any spouse or heirs of the patient and any children whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “client” herein shall mean both the mother and the mother’s expectant child. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the provider and its partners, associates, corporation, and the employees, agents, and estates of any of them, must be arbitrated including without limitation claims for loss of consortium, wrongful death, emotional distress or punitive damages. A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty (30) days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty (30) days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party’s own benefit. The parties agree that the arbitrators have the immunity of judicial officers from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law. Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator. The parties consent to the intervention and joiner in this arbitration of any person or entity which would otherwise be a proper additional party in a court action and upon such interaction and any existing court action against such additional person or entity shall be stayed. Any party may bring before the arbitrators a motion for summary judgment or summary adjudication. Discovery shall be conducted pursuant to applicable state law; however, depositions may be taken without prior approval of the neutral arbitrator. All claims based upon the same incident, transaction, or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by applicable laws relating to arbitration. If any of the provisions of this agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. NOTICE: BY SIGNING THIS AGREEMENT YOU ARE AGREEING TO HAVE ANY ISSUE OF MALPRACTICE DECIDED BY A NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL.
Informed-consent documents are used to communicate information about the proposed medical treatment of a disease or condition along with disclosure of risks and alternative forms of treatment(s). The informed-consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances. However, informed consent documents should not be considered all-inclusive in defining other methods of care and risks encountered. Your medical professional may provide you with additional or different information which is based on all of the facts pertaining to your particular case and the current state of medical knowledge. Informed-consent documents are not intended to define or serve as the standard of medical care. Standards of medical care are determined based on all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve.
Answer to Questions
The nature and purpose of the Treatment have been explained to me. I have read and understand this agreement. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment.
Release of Liability
I release Allure Med Spas Inc., medical staff, and specific technicians from liability associated with this Treatment. I certify that I am a competent adult of at least 18 years of age. This consent is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.
I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have sufficient opportunity for discussion and to ask questions. I consent to this Treatment today and for all subsequent treatments.
Informed Consent & Agree to Perform Treatment
My signature below acknowledges that the above information has been carefully read and fully understood by me and authorizes Allure Med Spas Inc., and its employees, independent contractors, associates, agents, and representatives (collectively and hereby known as, “Allure Medspa”,) to perform, implement, and/or assist in the Treatment I have elected to undergo. I agree that this agreement shall be effective for the first Treatment and for any and all subsequent Treatments I receive in the future. I acknowledge that this agreement constitutes full disclosure but may be supplemented by other verbal and/or written disclosures provided to me.
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I also understand and agree to assume the following risks and hazards which may occur in connection with any treatment including but not limited to unsatisfactory results, soreness, poor healing, and discomfort. I understand that even through precautions may be taken in my treatment, not all risks can be known in advance. Therefore, in consideration for any treatment received, I agree to unconditionally defend and hold harmless and release from any and all liability Allure Med Spas Inc. and the individual that provided my treatment, the location the treatment was provided and the insured and any additional insureds, as well as any officers, directors, or employees of the above companies for any condition or result, known or unknown, that may arise as a consequence of any treatment that I receive.