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Informed Consent For BOTOX

BOTOX® is an FDA approved purified protein that when administered in small doses, relaxes facial muscles by blocking overactive nerve impulses. Administered by trained healthcare professionals, Botox targets dynamic wrinkles which are caused by repeated muscular contractions, such as frowning and squinting. A non-surgical and non-invasive procedure, Botox can also target jaw muscles to reduce
bruxism and clenching, alleviating headaches and migraine pain. This makes Botox incredibly popular as both a cosmetic and therapeutic treatment. If the wrinkles are too deep, Botox may not get rid of them completely, and a more involved surgical procedure may be necessary. Botox treatment consists of a series of injections through a tiny needle to muscles of the face. The Botox takes about a week to take
effect, and the effects usually last usually about 3-4 months. Repeat injections are required to maintain the effect.


BOTOX® Cosmetic has been shown to be safe and effective when used to treat lines of facial expression. This is strictly a voluntary cosmetic procedure. No treatment is necessary or required. Alternative treatments include other forms of botulinum toxin, dermal fillers and surgical procedures.


Risks, undesired effects and side-effects include, but are not limited to the following :


  • Bruising: One of the possible undesired effects of Botox is the possibility of bruising at the injection site. Some medications, such as aspirin, warfarin, Coumadin, Motrin, ibuprofen, anti-inflammatory medications and vitamin E can increase these risks. If you are on any of these
    medications, your risk of bleeding or bruising will be higher. However, even without these medications, there is a risk of bruising just as with any injection. If bruising occurs, it usually lasts a few days.
  • Swelling & Redness: There may be some localized swelling and redness at the injection site that lasts a few minutes to a few hours.
  • Weakness of nearby muscles: Rarely Botox can diffuse to surrounding muscles, like the muscles of the eyelid (causing droopiness) or the muscles that control eye movement (causing double vision). In the case of injections around the mouth, Botox may interfere with whistling, drinking through a straw, chewing and pronunciation. To decrease these risks, it is recommended that you do not massage or press the area of the injections for the next 24 hours and that you refrain from bending, rigorous exercise and excessive heat for the next 24 hours.
  • Under correction & Overcorrection: Under correction (not enough effect), as well as
    overcorrection (too much effect) can occur. Botox may also result in facial asymmetry, where one side of the face looks different than the other. In the case of under correction, additional Botox can be administered. In the case of overcorrection, the effect will diminish over several
    weeks as the muscles regain their ability to contract.
  • Miscellaneous Side Effects: In the original study that described the use of Botox, one group of people received Botox, and the other did not receive Botox. Both groups experienced headaches, flu-like syndromes or respiratory infections, nausea, and weakness. These are all
    common symptoms that occurred at about the same rate in both the group that received Botox, and the group that did not receive Botox. So, although there is no indication that Botox is the “cause” of these side effects, it is important for you to be informed that you may experience
    these common occurrences after your Botox injection.
  • Permanent Loss of Muscle Tone: With repeated injections, permanent loss of the ability of the muscle to contract can result.
  • Antibodies to Botox: It is possible to develop antibodies to Botox. This will result in the Botox having minimal or no effect.
  • Allergic Reaction to Botox: Any medication or drug has the potential to cause allergic reactions in a small number of people. Symptoms of an allergic reaction can include rash, hives, itching, shortness of breath, and rarely death. In general, allergic reactions to medicines are more likely to occur in people who have allergies to other drugs, foods, or things in the environment, such as dust or grass. If you have allergies to other medicines, foods, or other things in the environment, or if you have asthma, let your doctor know.
  • Theoretical risks: Botox contains human-derived albumin and carries a theoretical risk of virus transmission. There have been no reports of disease transmission through Botox.


You must not have Botox if you are pregnant; nursing; allergic to egg or albumin; have an infection, skin condition or muscle weakness at the site of the injection; or if you have any neuromuscular diseases such as Eaton-Lambert syndrome, Lou Gehrig’s disease or myasthenia gravis.


The degree of muscle relaxation and the duration of the effect may vary in different people. Payment is expected upon scheduling the treatment, which is before the extent of success is determined. This procedure is an elective cosmetic procedure and not reimbursable by government or private healthcare insurers. Additional injections may be necessary, for which you will be charged a retouch fee, if optimal
effect is not reached in 10 to 14 days.


Photographs will be taken before and after treatments in order to monitor progression. I consent to the usage of such photographs provided the pictures do not reveal my identity.

Informed Consent For PRP & Microneedling

The blood will be drawn in our office using the same technique as having it drawn for routine lab testing. It is spun in a special centrifuge to separate its components, and to extract the most concentrated “platelet rich” portion of the plasma. Platelets are very small cells in your blood that are involved in the clotting and healing process. When PRP is injected into the damaged area it causes a mild inflammation that triggers a healing cascade. As the platelets organize in the treatment area, they release a number of enzymes to promote healing and tissue responses, including attracting stem cells and releasing growth factors to repair damaged tissue. As a result, new collagen and elastic fibers begin to develop. As the collagen matures, it begins to shrink, causing a tightening and strengthening of the tissue in the damaged area. When treating injured or sun and time damaged tissue, a remodeling of the tissue to a healthier and younger more elastic state occurs.

Treatment results are generally visible at 4 weeks and continue to improve gradually over 4 months when PRP is used alone or synergistically with fillers, lasers and skin pen (aka micro-needling). Most treatments require 60-90 minutes including the drawing and processing of your blood. Generally, 2-3 treatments are advised at intervals suited to the patient’s clinical skin and tissue health. Touchup treatments may be done once a year after the initial series of treatments to boost and maintain the results. Significant results can last as long as two years.


End results depend on many factors, including the aggressiveness of the treatment, adherence to post treatment care regimen, proper nutrition and good general health. The most important being the degree of cumulative sun and environmental damage to your skin and tissues.

Treatments are designed to maximize the results of the treatment within safe and predictable parameters. The number of treatments needed cannot always be accurately predicted, even under the best of circumstances. Appropriate intervals between treatments are needed to allow the healing process to complete the cycle. The next treatment is then decided upon, given the results of the previous one.

Good general health is the key to excellent and predictable outcomes by supporting your cells to work well and promote healing.

Any successful skin rejuvenation treatment is cumulative in the overall improvement of skin health, and therefore the skin’s appearance.

PRPs safety has been established for over 20 years for its wound healing properties. Its proven effectiveness has extended across multiple medical specialties including cardiovascular surgery, orthopedics, sports medicine, podiatry, neurosurgery, dermatology, urology, dental and maxillofacial surgery as well as aesthetic applications. PRPs use in wound healing, aesthetics and skin rejuvenation began in approximately 2004 in Europe and Asia. Areas typically treated for aesthetic purposes, volume restoration, and skin rejuvenation include the face, neck, lips and back of the hands. PRP is also used to stimulate hair growth in various forms of alopecia in both men and women. Because it is enriched plasma derived from one’s own blood, it is considered safe and effective for almost all skin tones and is virtually allergy free.


PRP has been shown to have overall rejuvenating effects on the skin including:

  • Improving skin texture to a more youthful appearance
  • Decreasing the appearance of fine lines and wrinkles
  • Increasing tissue volume via production of collagen and elastin
  • Diminishing and improving the appearance of scars
  • Improved texture and thickness to skin damaged by radiation therapy
  • Minimal down time and short recovery period
  • Very low risk
  • No general anesthesia required


There are very few contraindications to receiving PRP for aesthetic procedures. Parental consent is required for those under 18 years of age. Persons with the following conditions are not considered candidates:

  • Cancer, chemotherapy treatments
  • Acute or chronic infections, sepsis
  • Abnormal platelet function or blood disorders
  • Skin diseases or allergies
  • Any severe metabolic or systemic disease
  • The use of blood thinners or systemic corticosteroids


Potential side effects include:

  • Pain, bleeding, and/or bruising at the injection site
  • Flushing of the skin, swelling, itching
  • Allergy to the anticoagulant solution used to process the blood
  • Injury to a nerve and/or muscle
  • Infection as with any type of injection
  • Dizziness or fainting
  • Nausea or vomiting
  • Minimal effect from the treatment
    Remember, your own tissue will rarely if ever, do you harm.


  • Do nothing
  • Injections with neurotoxins (ex. Botox)
  • Injections with dermal filling agents (ex. Juvederm)
  • Laser and light based treatments
  • Chemical peels
  • Surgical intervention
  • PRP injections in combination with any of the modalities listed above


Each person has a unique response to PRP treatments. The outcome is generally very positive, but patience is necessary. The regeneration process can take months and multiple treatments may be required to achieve optimal results. Initial results are usually visible at 4 weeks, and texture and tone continue to improve gradually over the ensuing 3-6 months.


Areas that respond well to skin rejuvenation include:

  • Crinkling skin around the eyes
  • Cheeks and mid face
  • Neck
  • Jaw line
  • Décolletage and chest
  • Back of hands, arms
  • Lips
  • To stimulate hair growth in scalp


Advanced wrinkling cannot be reversed and only minimal improvement is predicted in persons with
drug, alcohol, or tobacco usage. Severe scarring may not respond. Current data shows results may last
18-24 months. Of course, all individuals are different, so there will be variations from one person to the

Informed Consent For Chemical Peel of the Skin

  1. A chemical peel involves the application of chemicals to the treatment area in order to encourage healthy exfoliation of the skin. The chemicals will cause a controlled, partial-thickness skin injury, which often leads to the peeling of superficial layers.
  2. Though the chemical peels available at our clinicare generally safe and effective treatment options, I understand and accept that, like any medical procedure, there are potential risks involved with treatment. Potential risks of chemical peels include, but are not limited to: infection, poor healing, pigmentation changes, redness, scarring, activation of heretic lesions, and change in skin texture.
  3. I understand clinical results may vary depending on individual factors, including medical history, skin type, compliance with pre/post treatment instructions, use (or non-use) of an effective treatment. I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.
  4. I confirm that I am not pregnant at this time, and that I have not taken Accutane® within the last 6 months. I do not have a history of Keloid scarring, have not had a phenol or deep chemical peel within the last year, and do not have poorly controlled diabetes. I have no active cold sores, acute facial dermatitis, open sores, or other facial irritation.
  5. It has been explained to me that optimum results often require a series of treatments. If I am purchasing the series, I have read and policies.
  6. I hereby give my consent for my picture to be taken for clinic use at IV Wellness Lounge Clinic and understand that it may be used for purposes such as treatment planning, documentation, research, and education.


I have read and understand the above information and have initialed each paragraph for confirmation. My questions regarding the procedure have been answered to my satisfaction. I accept the risks and would like to have a chemical peel treatment as discussed with the doctor at the clinic.

Informed Consent For Chemical Peel of the Dermal Filler

This form is not just a formality- it’s a record of your decision to consent to a procedure having considered the risk of both positive and negative outcomes and medical risks listed below and the impact they may have on your well-being. Please initial the boxes you have read, understood and discussed as required with your clinician.

What is being injected?
Hyaluronic acid injectables improve the appearance of lines, correct volume loss or alter proportions. They compose mainly of water, hyaluronic acid, lidocaine anaesthetic, and stabilising molecules such as BDDE (1,4-Butanediol Diglycidy Ether )

Risks of injection
Trauma during the procedure is caused by needles and cannulas passing through tissue, and includes bleeding, bruising, haematoma, damage to underlying structures including veins, arteries, nerves, salivary glands, lymph nodes, bone, muscle and other soft tissue structures are possible.

In rare cases this could cause continuous problems in appearance, sensation or function and may require medical intervention to treat or may be permanent.

Most traumatic injuries heal completely on their own.

Infection: Bacterial, viral or fungal infections can occur post procedure. Infections can cause redness and swelling and resolve or progress into abscesses or biofilms which can be slower to recover. Symptoms include itchiness and lump just under the skin.

Injections into the lip area could trigger a recurrence of cold sores which may require treatment.

Reactions rarely occur but can include an immediate reaction causing swelling, and very rarely life threatening anaphylaxis.

Delayed reactions localised to the skin can cause nodules, lumps or bumps or very rarely sterile abscesses. These may occur soon after the procedure or months later.

They may require treatment and may leave permanent effect on the appearance, sensation, and function of the areas affected.

Lumps, Bumps, Swellings- these side effects may be temporary or permanent.

I understand adjustments requiring more product incur a charge.

I understand that with all treatments the precise degree of improvement cannot be guaranteed. The outcome’s subjective nature also means dissatisfaction is a possible outcome regardless of effectiveness of treatment. I understand that the effect of all treatments may gradually wear off, additional treatments may be necessary to acquire the desired effect, and further charges will apply if more product is required.

By signing this form, you agree that you have read this form carefully and considered the side effects, risks and uncertainty of the outcome and decided the treatment is still in your best interests.

You have discussed all the details of the treatment plan, past treatments and your medical history with your clinician and shared all the information your clinician may need to plan a treatment.

You agree that the balance of the benefits and risks to you overall favour the use of dermall filler.

You understand that the initial treatment of side effects and complications is included in the cost of the procedure and therefore no refunds are issued due to any of the above occurring.

You agree for photographs to be taken for clinic use at IV Wellness Lounge Clinic and understand that it may be used for purposes such as treatment planning, documentation, research, and education.

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