BOTULINUM TOXIN TREATMENT
PATIENT NAME DATE OF BIRTH ADDRESS PHONE EMAIL EMERGENCY CONTACT: EMERGENCY CONTACT PHONE: RELATIONSHIP:
Have you had IV treatments before? YesNo If yes, what was your experience with IV therapy? Please check if you have ever had any of the following: Select any of the following Hypertension Angina Ankle Swelling Arrhythmia/Atrial Fibrillation Congestive Heart Failure MI/Heart Attack/Stroke Abnormal EKG Chronic Kidney Disease Generalized Edema Bleeding Disorder Clotting Disorder Asthma Pulmonary Edema Sudden Weight Loss Diabetes Anxiety/Panic Attacks G6PD deficiency
If yes, how many years? Have you used injectable street drugs? YesNo Do you have hepatitis B or C? YesNo Do you have HIV? YesNo How did you hear about us? FriendGoogleInstagramFacebookEmailOther
All therapeutic services performed by practitioners at ICON Anti-Aging & Aesthetics are aimed to prevent and treat pain, disease, or other dysfunction. Adverse side effects may result. These include but are not limited to, local bruising, minor bleeding, fainting, temporary pain or discomfort, a temporary aggravation of symptoms existing prior to receiving treatment. Practitioners at ICON Anti-Aging & Aesthetics may recommend and perform naturopathic medicine and utilize nutritional supplements as means of prevention or treatment modalities. Adverse side effects may result from taking nutritional supplements. These include but are not limited to; changes in bowel habits, temporary abdominal pain or discomfort, and the possible temporary aggravation of existing symptoms. If I experience any problems, to which I associate with the supplements, I understand that I should stop taking them and contact my practitioner promptly. The above treatment modality and related risks have been explained to me by my practitioner, and I had the opportunity to ask questions, I hereby consent to the treatment.
This document is intended to serve as confirmation of informed consent for IV therapy is offered by ICON Anti-Aging & Aesthetics
I have informed the specialist(s) of any known allergies to drugs or other substances, or of any past reactions to IV treatments or anesthetics. I’ve informed ICON Anti-Aging & Aesthetics of all current medications and supplements.
I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent
I understand that:
1) The procedure involves inserting a needle into a vein and injecting a solution.2) Alternatives to intravenous therapy are oral supplementation and / or dietary and lifestyle changes.3) Risks of intravenous therapy include but are not limited to the following:
4) Benefits of intravenous therapy include the following.
iii) Nutrients are forced into cells by means of high concentration gradient.
I am aware that other unforeseeable complications can occur. I do not expect the specialist(s) to anticipate and/or explain all risk and possible complications. I rely on the specialist(s) to exercise judgment during the course of treatment with regard to my procedure. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered. I understand that I have the right to consent to, or refuse any proposed treatment at any time prior to its performance. My signature on this form affirms that I have given my consent to ICON Anti-Aging & Aesthetics with any different or further procedures which, in the opinion of my specialist(s) or others associated with this practice, may be indicated.
My signature below confirms that:
I understand the information provided on this form and agree to the foregoing:1) The procedures set forth above has been adequately explained to me by my specialist2) I have received all of the information in explanation I desire concerning the procedure3) I authorize and consent to the performance of the procedures
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.
THE TREATMENTBotulinum toxin (Botox®, Xeomin) 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: a) glabellar area of frown lines, located between the eyes; b) crow’s feet (lateral areas of the eyes); c) forehead wrinkles; d) radial lip lines (smokers lines), e) head and neck muscles. Botox 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 and 9. Flu-like symptoms may occur.
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 myasthenis 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.
RESULTSI 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 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 and write in English.
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Document Name: BOTULINUM TOXIN TREATMENT
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