Please Complete The Following Consent Form
The purpose of this consent form is to provide written information regarding the risks, benefits and alternatives of treatment with botulinum toxin (i.e., Botox, Dysport, Xeomin, Jeuveau and similar agents). This material serves as a supplement to the discussion you have with your BLOOM HEALTH provider. It’s important that you fully understand this material, so please read this information thoroughly. If you have any questions regarding the procedure, ask your Bloom Health provider prior to submitting this consent form.
TREATMENT GOALS AND DESCRIPTION OF PROCEDURE
Repeated muscle contractions from frowning, squinting, or eyebrow raising can cause skin to furrow and fold, gradually resulting in unwanted facial lines. Botulinum toxin is a neuromodulator produced by the bacterium Clostridium, which blocks nerve impulses to temporarily relax muscles and reduce facial lines. Common areas of treatment include glabellar frown lines located between the eyes, forehead lines, crow’s feet (lateral areas of the eyes), and radial lip lines (smoker’s lines). Botulinum toxin is diluted to a controlled amount, and injected into the muscles with a very thin needle, as to be almost painless. Patients may feel a slight burning sensation while the solution is being injected. The procedure takes about 10-15 minutes and the results become fully apparent in 2-10 days.
TREATMENT RESULTS
Most patients are pleased with the results of their treatment. However, like any aesthetic 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. Botulinum toxin lasts temporarily and additional treatments will be needed periodically to maintain the full effects, generally every 3-4 months. The duration of your results depends on many factors including but not limited to: age, sex, tissue conditions, sun exposure, and your general health and lifestyle conditions.
AFTERCARE INSTRUCTIONS
Following your procedure, we’ll provide you with verbal and/or written aftercare instructions. These include, but may not be limited to the following: 1) Maintain an erect posture and avoid manipulating the injection areas for 3 hours post-treatment; 2) Avoid heavy lifting, straining and vigorous exercise for 6 hours post-treatment; 3) Abstain from facial laser treatments, microdermabrasion, facial peels, chemical peels and microneedling for at least 10 days; 4) If at any time you suspect you’re having an unexpected side effect, adverse reaction or complication, contact us immediately, and obtain help in an appropriate medical setting (i.e., BLOOM HEALTH, your primary care provider, specialist, urgent care, or acute care facility). I will adhere to the aftercare instructions supplied to me.
POTENTIAL RISKS AND COMPLICATIONS
Before undergoing this procedure, understanding the risks is essential. 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. 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) Rarely, post treatment bacterial, and/or fungal infection requiring further treatment; 5) Allergic reaction; 6) Flu-like symptoms; 7) Occasional numbness of the forehead lasting up to 2-3 weeks; 8) Transient headache; 9) Minor temporary droop of eyelid(s) (ptosis) in approximately 2% of injections, this usually lasts 2-3 weeks; 10) Heaviness in the brow and upper eyelids, due to decreased frontalis muscle tone.
PREGNANCY AND CONTRAINDICATED CONDITIONS
I am not aware that I am pregnant. 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), or Parkinson’s. I do not have any known allergies to the toxin ingredients, or to human albumin.
ALTERNATIVE THERAPY
I understand that this is an elective procedure with goal of improved aesthetic appearance and that the main alternative to therapy is to observe and not receive any treatment. Other available therapies might include sun protection, moisturizers, microneedling, skin resurfacing, or surgery.
PAYMENT
I understand that this service is not covered by insurance, and payment is my responsibility and is expected at the time of treatment.
RIGHT TO DISCONTINUE TREATMENT
I understand that I have the right to discontinue the procedure at any time.
RELEASE OF LIABILITY
I hereby indemnify BLOOM HEALTH, PLLC from any liability relating to the procedures that I have volunteered for. I understand that any treatment performed is between me and the doctor/healthcare provider who is treating me and I will direct all post-treatment questions or concerns to the treating clinician. Furthermore, 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.
CONSENT TO TREATMENT
By entering my initials below, I hereby voluntarily consent to treatment with botulinum toxin injections for facial dynamic wrinkles or other cosmetic purposes, as performed by my BLOOM HEALTH provider. I have read the above and understand it. I state that I read and write in English. I am not under the influence of drugs or alcohol. The treatment has been fully explained to me and my questions have been answered satisfactorily. I accept the risks and complications of this elective procedure and I understand that no guarantees are implied as to the outcome of the procedure. Please note this consent is valid for all future botulinum toxin injections I choose to receive from BLOOM HEALTH.
