Event Tox Consent & Paperwork

Treatment with dermal fillers (such as Juvederm and or Restylane products) can smooth out facial folds and wrinkles, add volume to the lips, contour facial features that have lost their volume and fullness due to aging, sun exposure, illness, etc. Facial rejuvenation can be carried out with minimal complication. These dermal fillers are injected under the skin with a very fine needle. This produces natural appearing volume under wrinkles and folds which are lifted up and smoothed out. The results can often be seen immediately but may expand within 1-4 weeks to final fullness effect.

The purpose and cosmetic nature of this procedure/treatment: The injection of a very small amount of Botox and or Jeuveau, a purified toxin produced by the bacteria clostridium botulinum, into the specific muscle causes weakness or paralysis of that muscle. This results in relaxation of the muscle and improvement of the lines or wrinkles that the muscle action has formed, with results lasting 3-6 months.

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: post treatment discomfort, swelling, redness, bruising, and discoloration; post treatment infection associated with any transcutaneous (skin) injection; allergic reaction; reactivation of herpes (cold sores); lumpiness, visible yellow or white patches; granuloma formation; localized necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occurs.

Known significant risks have been disclosed, yet the theoretical risk of unknown complications does exist. Possible risks and complications of Botox and/or Jeuveau which may include: Transient Headache, Swelling, Bruising (Substances that increase this risk include Vitamin E, Aspirin, Motrin, other Nonsteroidal Anti-Inflammatory drugs and blood thinning medications such as Coumadin. I understand if I have taken any of these products in the past 7 days the procedure may not be recommended), pain during injection, twitching, itching, or numbness, asymmetry (unevenness) and/or temporary drooping of eyelids or eyebrows. 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: post treatment discomfort, swelling, redness, bruising, and discoloration; post treatment infection associated with any transcutaneous (skin) injection; allergic reaction; reactivation of herpes (cold sores); lumpiness, visible yellow or white patches; granuloma formation; localized necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occurs.

I am not aware that I am pregnant. I am not trying to get pregnant. I am not lactating (nursing). I do not have or have not had any major illnesses which would prohibit me from receiving Botox and/or Jeuveau and/or dermal fillers. I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to lidocaine.

I understand that this is an “elective” procedure, and that payment is my responsibility and is expected at the time of treatment

I understand that I have the right to discontinue treatment at any time.

I authorize the taking of clinical photographs and and videos such as before and after pictures and their use for scientific and treatment purposes.

I authorize the taking of clinical photographs and and videos such as before and after pictures and their use for marketing purposes, before and after treatments.

Dermal Fillers have been shown to be safe and effective when compared to collagen skin implants and related products to fill in wrinkles, lines and folds in the skin on the face. Their effect can last up to 12-18 months. Most patients are pleased with the results of dermal fillers use. However, like any esthetic 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. The dermal filler procedure is temporary and additional treatments will be required periodically, generally within 4-6 months, involving additional injections for the effect to continue. I am aware that follow-up treatments will be needed to maintain the full effects. I am aware the duration of treatment is dependent on many factors including but not limit to: age, sex, tissue conditions, my general health and life style conditions, and sun exposure. The correction, depending on these factors, may last up to 13 months and in some cases shorter and some cases longer. I have been instructed in and understand the post-treatment instructions.

Response is usually between 7-10 days after injection. Typically, the muscle action (wrinkles) will return in 4-5 months. At this point a repeat treatment can relax the muscle and soften the lines again. I understand there is no guarantee that wrinkles and folds will disappear completely and or that you will require additional treatments to achieve the results you see. I agree to follow up in 2-4 weeks after my first treatment, if asked to do so by my physician.

I have read the important information and care instruction files that are available on this page for download.

DISCLAIMER: By typing your name above, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.