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Botulinum Injection Consent

I hereby authorize Dr. and such assistants as may be selected to perform the following procedure or treatment: BOTULINUM TOXIN INJECTION FACE or BODY (the patient may list specific areas to be injected i.e. forehead, crows-feet, face and/or lips)

I recognize that during the procedure and medical treatment or anesthesia, unforeseen conditions may necessitate different procedures than those above. I therefore authorize the above physician and assistants or designees to perform such other procedures that are in the exercise of his or her professional judgment necessary and desirable. The authority granted under this paragraph shall include all conditions that require treatment and are not known to my physician at the time the procedure is begun. Initial

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. Initial

I acknowledge that no guarantee or representation has been given by anyone as to the results that maybe obtained. Initial

I consent to be photographed or televised before, during, and after the operation(s) or procedure(s) to be performed, including appropriate portions of my body, for medical, scientific or educational purposes, provided my identity is not revealed by the pictures. Initial

For purposes of advancing medical education, I consent to the admittance of observers to the treatment room. Initial

I authorize the release of my Social Security number to appropriate agencies for legal reporting and medical-device registration, if applicable. Initial

I understand that the surgeons' fees are separate from the anesthesia and hospital charges, and the fees are agreeable to me. If a secondary procedure is necessary, further expenditure will be required Initial

I realize that not having the operation is an option. Initial

IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:

THE ABOVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN
THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT
THERE ARE RISKS TO THE PROCEDURE OR TREATMENT PROPOSED

I consent to the procedure and the listed items (1-10) and am satisfied with the explanation.

Signature

Today's Date

witness

Consent to Medical/Surgical Office Procedure

I, (or my authorized representative, i.e., parent guardian) consent to the medicaVsurgical procedures outlined below to be performed by and his/her staff, associates, or assistants to whom the physician(s) performing the procedure may assign designated responsibilities. In the event one or more of the physicians is unable to perform or complete the procedure, a qualified substitute physician will perform or complete the procedure. The proposed medical/surgical procedure is for the diagnosis/treatment of:

The procedure has been explained to me in terms that I understand. The explanation included:

The nature and extent of the procedure to be performed.
The most frequently occurring risks of the procedure involved. and those risks which are unlikely to occur, but which may involve serious consequences, include but are not necessarily limited to the following:
General risks may include pain, scarring, bleeding and infection.
The benefits of the procedure.
The estimated period of incapacity or convalescence, if any
The risks and benefits of any reasonable alternatives to this procedure include having no treatment at all.

I was given the opportunity to ask any questions I may have regarding the procedure, and I have had those questions answered to my satisfaction.

I understand that I may consult or could have consulted with another physician about this procedure.

I understand that I have the right to refuse any medical/surgical treatment recommended at any time prior to its performance.

I authorize my physician to perform such additional procedures which in his/her judgment are incidentally necessary or appropriate to carry out my diagnosis/treatment.

If any unforeseen condition arises during this procedure which requires transportation to a hospital, additional procedures, operation or medication including anesthesia and blood transfusions, I further request and authorize my physician to do whatever he/she deems advisable on my behalf.

I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees have been made to me concerning the results of this procedure.

I authorize the physician performing the procedure, or his/her staff, associate, or assistant to whom the physician may assign the responsibility, to use his or her discretion in disposing of or using any tissue or body parts that may be removed during the procedure set forth above, subject to the following conditions (if any):

I authorize that a physician in training may participate in my care; a representative or technician from a medical device company may be present at the procedure; medical photography may be utilized for medical, scientific, or educational purposes, provided my identity is not revealed in the photo or text.

I acknowledge that I have read (or had read to me) and fully understand the above information. Furthermore, I certify that all my questions and concerns regarding the procedure, its attendant risks, benefits and alternatives have been explained to my satisfaction. I hereby authorize my physician to perform the above discussed procedure.

Patient Initials

Patient Signature

(Guardian’s Signature if Patient is under 18)

Today's Date

Date of Birth

Sedative Analgesia [Moderate Sedation; Conscious Sedation]

I understand the administration of sedative analgesia is recommended. The benefit of sedation is greater comfort throughout the procedure. It has been explained to me that all forms of sedation involve some risks. I understand that no guarantees or promises can be made concerning the results of my procedure or the sedation technique administered. Complications with sedative analgesia can occur and include inadequate sedation, drug reaction, the possibility of infection, bleeding or injury to blood vessels at the intravenous site. More severe complications could include depression of respiration and heart problems that could lead to serious consequences, including even loss of life. Alternatives to sedation include no sedation at all and have been explained to me.

I acknowledge that I have read (or had read to me) and understand the above information on sedative analgesia. Furthermore, I certify that all my questions and concerns regarding the administration of conscious sedation, its attendant risks, benefits and alternatives have been explained to my satisfaction. I agree not to drive a car, operate machinery or make any legal decision within 24 hours as the effect of sedation may remain in my system for this period. hereby authorize my physician and/or individuals qualified to do so, to administer this analgesic.

Patient Initials

Today's Date

Date of Birth

Time

Witness To Signature

Signature

informed consent for dermal filler treatment

Patient Name

Date Of Birth

Mailing Address

Phone Number (Cell)

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. Initial

THE TREATMENT

Treatment with dermal fillers (such as Juvederm, Restylane, Radiesse 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. Initial

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 blood vessel occlusion occurs. Initial

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 ittnesses which would prohibit me from receiving dermal fillers. certify that do not have multiple allergies or high sensitivity to medications, including but not limited to lidocaine. Initial

ALTERNATIVE PROCEDURES

Alternatives to the procedures and options that I have volunteered for have been fully explained to me. Initial

PAYMENT

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

RIGHT TO DISCONTINUE TREATMENT

RIGHT TO DISCONTINUE TREATMENT. Initial

TRAINING COURSE

I understand that I have volunteered to be a model patient in a training course and the doctor [healthcare professional who will be treating me has had limited experience with the method of treatment. Initial

I hereby indemnify Elpis Healthcare, PLLC from any liability relating to the procedures that I have volunteered for. I also understand that any treatrnent 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. Initial

I hereby indemnify the facility/meeting room/hotel where this treatment is being performed from any liability relating to the procedures that I have volunteered for. Initial

PUBLICITY MATERIALS

I authorize the taking of clinical photographs and videos and their use for scientific and marketing purposes both in publications and presentations. During courses given by Common Sense Dentistry and/or Elpis Healthcare. I understand that photographs and videos may be taken of me for educational and marketing purposes. I hold Elpis Healthcare harmless for any liability resulting from this production. I waive my rights to any royalties, fees and to inspect the finished production as well as advertising materials in conjunction with these photographs. Initial

RESULTS

Dermat 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 fillers 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 life style conditions, and sun exposure. The correction, depending on these factors, may last upto 6 months and in some cases shorter and some cases longer. I have been instructed in and understand the post-treatment instructions. Initial

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 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, understand and write in English. Initial

I am the treating healthcare professional. 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 wpy of this informed consent. The patient has been told to mntact my offe should they have any questions or mncerns after this treatment proædure.

Primary Care Clinic In Euless TX

Informed Consent Form

Botulinum Injection Consent