Hello.
We'd like to get to know you.
Your information is confidential and is saved to your account. A copy of this form is available upon request.
Bloom Health maintains compliance with the Health Insurance Portability and Accountability Act (HIPAA). HIPAA provides certain rights and protections to you as the patient, including protection of your Personal Health Information (PHI). HIPAA sets forth rules and restrictions on who has access to your PHI. If you'd like to view our HIPAA policy in its entirety, please click
here. By clicking YES below, I acknowledge this privacy notification.
I verify that I have read and fully understand this questionnaire. I have responded to the questions truthfully. I understand that withholding information or providing misinformation may result in unforeseen side effects or complications. I am aware that it is my responsibility to inform Bloom Health and my treating provider of any updates to my health history. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. While all treatments are recommended to achieve the best possible results, I understand that not all treatments will have the same result for every client, therefore no guarantee can be given. The treatments I receive from Bloom Health are voluntary and I release Bloom Health, PLLC from liability and assume full responsibility thereof.
Purpose of This Consent Form
The purpose of this section is to provide written information regarding the risks, benefits, and alternatives of treatment with neuromodulators, including Botox®, Dysport®, Xeomin®, Jeuveau®, and Daxxify®. This material serves as a supplement to the discussion you have with your Bloom Health provider. It is important that you fully understand this information, so please read thoroughly. If you have any questions, please speak with your Bloom Health provider prior to submitting this consent form.
Treatment Goals and Description of Procedure
Neuromodulator treatments involve the precise injection of botulinum toxin type A into targeted facial muscles to temporarily relax their activity. The goal is to soften expression lines, improve facial balance, and create a refreshed, natural appearance. Common treatment areas include the forehead, frown lines (glabella), crow’s feet, brow lift, lip lines, chin, neck bands, and masseters. The procedure is minimally invasive, typically takes 10–20 minutes, and requires little to no downtime. Results develop gradually over 3–14 days and generally last 3–4 months, depending on dose, muscle strength, and individual metabolism.
Treatment Results
While most patients experience visible improvement within two weeks, individual results vary. Neuromodulator treatments are temporary and require maintenance to sustain results. Some patients may notice the effect lasting longer or shorter than average. Repeated, consistent treatments can improve longevity and overall outcome. The goal is improvement, not perfection; no guarantee can be made regarding specific results.
Aftercare Instructions
Following your treatment, you will receive written and/or verbal aftercare instructions. These include, but may not be limited to: 1) Avoid rubbing, massaging, or applying pressure to treated areas for at least 24 hours; 2) Remain upright for 4 hours after injection; 3) Avoid strenuous exercise, saunas, and alcohol for the remainder of the day; 4) Minor redness, swelling, or pinpoint bruising may occur and typically resolves within several days; 5) Contact us immediately if you experience any unusual or prolonged symptoms.
Potential Risks and Complications
Although neuromodulator injections are widely used and generally considered safe, all medical procedures carry some degree of risk. Potential side effects include, but are not limited to: 1) Redness, swelling, tenderness, or bruising at the injection site; 2) Temporary headache or mild flu-like symptoms; 3) Uneven results or asymmetry; 4) Drooping of the eyelid or brow (ptosis), double vision, or uneven smile; 5) Temporary weakness of nearby muscles; 6) Rare allergic reaction. These effects are typically mild and resolve spontaneously, but in rare cases may persist for weeks or months.
Pregnancy and Contraindicated Conditions
I am not aware that I am pregnant. I am not trying to become pregnant. I am not currently breastfeeding. I have notified my Bloom Health provider of any medical conditions, medications, or recent facial procedures. I do not have a history of neuromuscular disorders (such as myasthenia gravis or Lambert-Eaton syndrome) or any infection at the intended treatment site.
Alternative Therapy
Neuromodulator treatment is elective. Alternatives may include dermal fillers, microneedling, laser resurfacing, radiofrequency tightening, topical skincare, or no treatment at all. Your provider will help determine the best approach for your goals.
Payment
I understand that neuromodulator treatments are cosmetic and not covered by insurance. Payment is my responsibility and is due at the time of treatment.
Right to Discontinue Treatment
I understand that I have the right to discontinue treatment at any time.
Release of Liability
I hereby release and hold harmless Bloom Health, PLLC, and its affiliates from any liability associated with this elective procedure. I understand that my Bloom Health provider is licensed and trained to perform this treatment, that results vary, and that all post-treatment questions or concerns should be directed to my provider.
Consent to Treatment
By entering my initials below, I voluntarily consent to receive neuromodulator injections (Botox®, Dysport®, Xeomin®, Jeuveau®, or Daxxify®) as performed by my Bloom Health provider. I acknowledge that I have read and understand the information above. I am not under the influence of drugs or alcohol, and all of my questions have been answered to my satisfaction. I understand the potential risks and benefits of this elective procedure. This consent applies to all future neuromodulator treatments I choose to receive at Bloom Health.
