Intake Form Aesthetics Consent

THE TREATMENT
Treatment with dermal fillers (such as Juvederm Ultra, Juvederm Ultra Plus, Juvederm Voluma, Ravanesse Versa, and others) can smooth out facial folds and wrinkles, add volume to the lips, and contour facial features that have lost their volume and fullness due to aging, sun exposure, illness, etc. Facial rejuvenation can be carried out with minimal complications. These dermal fillers are injected under the skin with a very fine needle. This produces natural appearing volume under wrinkles and folds, which are lifted up and smoothed out. The results can often be seen immediately.

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, bruising, and discoloration
2. Post-treatment infection associated with any transcutaneous injection
3. Allergic reaction
4. Reactivation of herpes (cold sores)
5. Lumpiness, visible yellow or white patches
6. Granuloma formation
7. Localized necrosis and/or sloughing, with scab and/or without scab, if a blood vessel occlusion occurs.

PREGNANCY AND ALLERGIES
I am not aware that I am pregnant. I am not trying to get pregnant. I am not lactating (nursing). I do not have or have not had any major illnesses which would prohibit me from receiving dermal fillers. I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to lidocaine.

RESULTS
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 can last up to 6 months. Most patients are pleased with the results of dermal filler use. However, like any esthetic 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 treatment to achieve the results you seek. The dermal filler procedure is temporary, and additional treatments will be required periodically, generally within 4-6 months, involving additional injections for the effect to continue. I am aware that follow-up treatments will be needed to maintain the full effects. I am aware the duration of treatment is dependent on many factors including but not limited to: age, sex, tissue conditions, my general health and lifestyle conditions, and sun exposure. Depending on these factors, the correction may last up to 6 months and in some cases shorter and others longer. I have been instructed in and understand the post-treatment instructions.

I understand this is an elective procedure and I hereby voluntarily consent to treatment with dermal fillers for facial rejuvenation, lip enhancement, establish proper lip and smile lines, and replacing facial volume. The procedure has been fully explained to me. I also understand that any treatment performed is between me and the healthcare provider who is treating me and I will direct all post-procedural 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 healthcare professional who treated me immediately.

THE TREATMENT
Botulinum toxin (Botox®, Xeomin, Dysport) 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:

1. glabellar area of frown lines, located between the eyes
2. crow’s feet (lateral areas of the eyes)
3. forehead wrinkles
4. radial lip lines (smokers lines)
5. head and neck muscles.

BOTOX has been approved to treat certain conditions involving crossed eyes (strabismus), eyelid spasm (blepharospasm), cervical dystonia (spastic muscle disorder with the neck), and motor disorders of the facial nerve (VII cranial nerve). BOTOX has also been used to aid in management of migraine headaches, colorectal disorders, excessive perspiration disorders of the armpit and hands, musculoskeletal pain disorders and upper and lower limb spasticity.

Botulinum toxin injections are customized for every patient, depending on his or her particular needs. These can be performed in areas involving the eyelid region, forehead, and neck. Botulinum toxin injections cannot stop the process of aging. It can however, temporarily diminish the look of wrinkles caused by muscle groups. Botulinum toxin injections may be performed as a singular procedure or as an adjunct to a surgical procedure.

Botulinum toxin 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
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.

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 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.

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 healthcare provider who is treating me and I will direct all postoperative 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 healthcare professional who treated me immediately.

THE TREATMENT
Microneedling/Microchanneling is an epidermal micro-exfoliant (EME). The device is used to stimulate the skin's tissue uses tiny needles to pierce the skin in a controlled and precise pattern to improve the appearance of skin. These microscopic injuries in the top layer of the skin stimulate the body’s natural healing process resulting in increased elastin and collagen production. This process works to tighten, lift and rejuvenate the skin giving a smoother, firmer, younger looking appearance. It is effective in reducing fine lines and wrinkles, sun damage and pigmentation, stretch marks, surgical and acne scars. This procedure is normally completed in 30-60 minutes depending on the treatment required.

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. Post-treatment infection is a possibility whenever the skin surface is disrupted which can lead to scarring.
3. Scarring is a rare occurrence, but it is a possibility if the skin surface is disrupted.
4. Allergic reactions
5. Potential increased sensitivity, irritation/itching or allergic reaction of the skin due to skin surface disruption.
6. Dilated Pores
7. Granulomas
8. Milia/acne formation with use of ointments that occlude hair follicles, sweat ducts, or sebaceous ducts.
9. Risk of burning, blistering, or bleeding of treatment areas with picking or scratching the sites

PREGNANCY, ALLERGIES AND CONTRAINDICATIONS
I am not aware that I am pregnant. I am not trying to get pregnant. I am not lactating (nursing). I do not have or have not had any major illnesses which would prohibit me from receiving dermal fillers. I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to lidocaine. Although it is impossible to list every potential risk and complication, I understand the following are recognized as known contraindications to microneedling/microchanneling: recent ablative dermal procedures, acne, rosacea, diabetes, history of any types of cancer or suspicious lesions or moles, raised lesions or keloid scars, scleroderma, collagen vascular diseases or cardiac abnormalities, a hemorrhagic disorder or hemostatic dysfunction, active bacterial or fungal infection, autoimmune disease or any condition that may weaken your immune system.

RESULTS
I understand, after the procedure the skin will be red and flushed in appearance similar to a moderate sunburn. You will experience a feeling of tightness and possibly a mild irritation to the skin afterwards that will diminish greatly over the next few hours. It is not common but occasionally mild bruising can occur depending on the depth the needles are being used at and the client. Peeling and dry skin is common for up to a week afterwards as skin cells are turning over and new ones are surfacing. Very rarely clients will experience minimal scabbing. I understand that results may vary between individuals.

I understand that although I may see a change after my first treatment, and results vary, microneedling/microchanneling treatments are not permanent, and additional treatments may be needed in the future due to natural degradation. I understand that even though good results are expected, the possibility of complications cannot be anticipated. The procedure has been fully explained to me. I also understand that any treatment performed is between me and the healthcare provider who is treating me and I will direct all postoperative 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 healthcare professional who treated me immediately.

Some patients experience mild to moderate discomfort during the aesthetic treatments, and for this reason we offer the use of a topical anesthetic cream. In some instances, the cream may cause a temporary local irritation in individuals who are sensitive to the active ingredients. Although very rare, other more serious side effects can occur. People with a known sensitivity to local anesthetics (Benzocaine, Lidocaine, Tetracaine) should not use this product. If you have been diagnosed with a cardiac or liver condition, take cardiac medication, or are currently pregnant or breastfeeding you should not use this product. This product will not be applied to large surface areas or multiple body sections during a single procedure (or within a 24hr period).

My questions regarding the procedure have been answered satisfactorily. By signing below, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks. I hereby give consent to perform this and all subsequent treatments with the above understood. I hereby release the doctor, the provider and the facility from liability associated with this procedure.

Aesthetic treatments are a visually oriented specialty. As such it is necessary that photographs be taken before, during, and after an aesthetic procedure or treatment. This allows for proper planning before procedures and follow-up evaluation afterward.

Photographs are required only for the body part in question. Due to the nature of aesthetic procedures and treatments, this may include face. Consent is required to take such images.

These materials are very important to ensure continued understanding of the treatments available to all patients. Please read carefully the information contained in both sections below, and provide your consent.

CONSENT TO TAKE PHOTOGRAPHS
I hereby authorize Liquid Mobile and its associates or licensees to take pre-procedural and post-procedural photographs.

I consent to the use of these images for the purposes of pre-procedural planning and post-procedural evaluation and I understand that they shall be made a part of my medical record.

I understand that this is an "elective” procedure and that payment is my responsibility and is expected at the time of treatment.

I understand that I have the right to discontinue treatment at any time.

I understand that results will vary among individuals. I understand that although I may
see a change after my first treatment, I will likely require a series of sessions to obtain
my desired outcome. The procedure and side effects have been explained to me including alternative methods, as have the advantages and disadvantages.

I am advised that though good results are expected, the possibility and nature of
complications cannot be accurately anticipated and that, therefore, there can be no
guarantee as expressed or implied either as to the success or other result of the
treatment. I state that I have read (or it has been read to me) and I understand this consent and I understand the information contained in it. I have had the opportunity to ask any questions about the treatment including risks or alternatives and acknowledge that all my questions about the procedure have been answered in a satisfactory manner.