Consent
Please ensure that you had all of your questions answered before signing!
BOTOX CONSENT I am aware that a neuromodulator (Botox, Dysport, Xeomin) is injected into a muscle that causes a temporary reduction
in the strength of muscle contraction. This effect may start to occur in 3–4 days after injection at full results within 14 days. The duration of
the effect on average is 3 months, but can be shorter or longer. I understand that the goal of treatment is to soften the muscle contraction and not to eliminate the movement completely. A successful treatment has an 80-90% reduction in movement so that I can still have facial
expression. Neuromodulators do not affect well established and deep wrinkles. After injection I agree to stay in an upright position for 3
hours to prevent migration of the product to another muscle. I will contract the muscles that were injected every few minutes for one hour to ensure the neuromodulator is absorbed into the muscle injected. I agree not to massage or manipulate the area for three hours after injection.
I understand that re-treatment of the area with a neuromodulator will happen only after the effect has completely worn off. Re-injection of a muscle that is weakened from a neuromodulator can result in an increase in the risk of unwanted side effects such as migration and eyelid droop. I am aware that at any time I can develop a tolerance to a neuromodulator which can appear as a reduction in effect or a reduction in length of time the muscle is weakened. I understand that it is in my best interest to avoid blood thinners such as alcohol, aspirin products, NSAIDS, high dose garlic, ginseng, gingko or other herbal supplements up to three days before treatment. I understand that I am to avoid strenuous physical exercise, hot tub, saunas, facials, alcohol and or aspirin/ NSAIDS for 24 hours after treatment.
Risks and Complications
I understand that a neuromodulator can cause temporary eye droop in up to 2% of all injections and that this is a risk each time I receive an
injection. This effect can last up to 4 months. Possible side effects include transient headaches, bruising, redness, swelling at the site of
injection, transient numbness. Bruising can last up to 7 days and be substantial in size or colour depending on the area injected. In the event of a headache, acetaminophen is recommended. When the lower face is injected with a neuromodulator, there is a risk of change in lip pursing, ability to enunciate words, sip from a straw or cup or mouth droop. This effect is temporary. I am aware and understand that my results are not guaranteed and may or may not fall within the expected outcomes.
FILLER CONSENT
Hyaluronic acid fillers are injectable gels that are used to restore volume to skin, correct facial lines, wrinkles and folds as well as to alter facial contours. Fillers are temporary and can last anywhere from 6 to 18 months depending on the type of filler used, the location injected and the number of syringes used. In the first few days after injection the filler is movable. I understand that I am not to manipulate the area injected and I should sleep on my back. I understand that it is in my best interest to avoid blood thinners such as alcohol, aspirin products, NSAIDS, high dose garlic, ginseng, gingko or other herbal supplements up to three days before treatment. I understand that I am to avoid strenuous physical exercise, hot tub, saunas, facials, alcohol and or aspirin/ NSAIDS for 24 hours after treatment.
Risks and Complications
The use of and indications for filler injection has been explained to me and I have had the opportunity to have my questions answered. I
understand that after injections it is common to experience pain at the site of injection, redness, swelling, bruising, itching, infection and/or
discolouration. Bruising/swelling can be quite substantial and last 7 days or longer. These reactions typically resolve spontaneously. Other
types of rare reactions include a hypersensitivity or allergic reaction to the gel and keloid scarring. An extremely rare adverse event is arterial or vein embolism. This occurs when the gel is injected into a blood vessel and can result in severe skin breakdown or blindness. Filler can move from the site of injection when under pressure and this can result in facial asymmetry. With lip injections there is a possibility of provoking a cold sore (Herpes) infection. I am aware and understand that my results are not guaranteed and may or may not fall within the expected outcomes.
Photographs
I authorize the taking of clinical photographs and their use for my personal treatment. I understand my identity will be protected.
Pregnancy and Neurological Disease
I am NOT pregnant, nor do I have any signifcant neurological disease (including muscular sclerosis).
I have read the above and understand it. My questions have been answered satisfactorily by the doctor. I accept the risks and complications of the procedure.