Download registration and medical history forms

PATIENT INFORMATION/MEDICAL HISTORY
Name:____________________________________Date:_____________ Age:________
Address:_______________________________________________________________
Street
City
State
Zip Code
Phone: Home:__________________Work:________________Cell:________________
Date of Birth:______________ Marital Status:_________
EMAIL:________________________________________
Employer:__________________________________ Occupation:_________________
Emergency Contact:__________________________ Relationship:________________
Phone: Home:_________________Work:_________________Cell:________________
Health History
Medication (prescription and over the counter; vitamins, herbal medications)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Allergies:_______________________________________________________________
Surgeries/Dates:_________________________________________________________
______________________________________________________________________
Have a History of?
__Heart Disease
__Excessive Bleeding
__High Blood Pressure
__Other
__Mental Disease
__Auto-immune Disorders
__Liver Disease
__Neuro-muscular Disease
__Diabetes
__Cold Sores/Fever Blisters
______________________________________________________________________
Are you? Pregnant_______ Nursing______
Do you? Smoke_____Drink Alcohol_____ Amount per day___________________
The above information is true and accurate to the best of my knowledge.
________________________________________________
Patient Signature
_________________
Date
BOTOX Consent Form
Patient Name:____________________Date:_____________
Consent Procedure: You have the right to be informed and educated
about your treatment(s). This will allow you to make an informed
decision whether or not you wish to undergo the actual treatment. You
have the right to read this consent form, ask any questions you may
have, and have them answered to your satisfaction prior to receiving any
treatment.
BOTOX® Cosmetic therapy for wrinkles is an injection treatment
designed to reduce facial expression lines. BOTOX® Cosmetic is the
trade name for botulinum purified neurotoxin complex. The injection of
BOTOX® Cosmetic for this purpose has been explained to me and my
questions regarding such treatment, its alternatives, (such as
dermabrasion, chemical peeling, laser resurfacing, dermal filler
injections, face-lifting, brow lifting and other surgery, Retin-A, Renova or
alpha hydroxy acids) its complications and risks have been answered.
The information given me has been in clear terms and I understand the
risks and complications of the treatments. I understand that the FDA has
approved BOTOX® Cosmetic only for the glabellar region and that
injection into any area other than the glabellar area is considered offlabel use. The treatment plan is to inject a small amount of BOTOX®
Cosmetic, a purified neurotoxin produced by the Clostridium bacteria,
into a targeted facial muscle to intentionally produce weakness or
temporary paralysis of that muscle. This results in the relaxation of the
muscle and improvement of the lines and wrinkles that the targeted
muscle action produced or improved contour of the face. Although
results are frequently dramatic, as high as 10% of patients may not
respond to these treatments for unknown reasons. In these patients,
BOTOX® Cosmetic will not work as well or for as long as would
ordinarily be expected. Repeated sessions may be necessary in certain
muscle groups to obtain the desired results.
Initial__________
BOTOX® Cosmetic works best for “dynamic” lines and wrinkles, that
means those lines that are directly associated with the muscle
movement. BOTOX® Cosmetic is less effective for fine textural changes
on the skin surface, and for those lines present at rest.
BOTOX® Cosmetic is temporary; meaning it will have to be repeated on
a regular basis to remain effective. How long each treatment lasts will
depend on many individual factors including the degree of skin sun
damage present, the depth of the lines, the size of the muscles, the
amount and strength of neuro-muscular repair. An average response is
3-6 months of diminished muscle contraction; individual responses may
be longer or shorter, depending on the above factors.
After BOTOX® Cosmetic is placed into the targeted muscles, the
weakening effect gradually begins over 3-5 days, and is not complete for
2 weeks. Therefore, optimal results are not seen for at least two weeks
and sometimes longer. During this period you may notice asymmetry, or
unevenness within the treated areas. This asymmetry will usually
correct itself as the Botox takes effect.
There is no known permanent side effect of BOTOX® Cosmetic for
wrinkles. There are, however, several well-known side effects that are
temporary.
Initial__________
These include the following:
Bruising. Usually at or near the injection site, may be increased with
the use of aspirin or aspirin like products, including Vitamin E. This
effect generally clears within 7-10 days. No treatment is necessary.
Headache. Related to the actual injections, is usually mild and transient
lasting less than 24 hours. May be relieved with Tylenol.
Pain at the Injection site. Similar to headache above, is usually mild,
transient and relieved with Tylenol.
Asymmetry. As described above, if present, noticed within the first two
weeks of therapy. May be corrected with “touch-up” injections, if
necessary.
Muscle twitching. Unusual, transient may be corrected with “touch-up”
injections.
Numbness. Actually a change in sensation noticed by some Botox
patients in the treated areas, better described as a “dullness.” It is
usually only noticed for a few days after treatment. Treatment is not
necessary.
Eyebrow or eyelid ptosis (drooping) and double vision (diploplia).
Seen in 1-2% of patients receiving Botox therapy, is temporary lasting 24 weeks and usually mild. May be treated with special eye drops, or if
necessary, patching of the affected eye.
Initial_____
If you are pregnant, or breastfeeding, Botox treatments are not
recommended.
If you have a history of neurologic (nervous system) disease, especially
if it is currently active, you may not be a good candidate for BOTOX®
Cosmetic. This should be discussed with your treating neurologist or
physician caring for your neurologic disease, prior to receiving BOTOX®
Cosmetic.
If you are currently taking aminoglycoside antibiotics or penicillamine,
you may need to discuss further your ability to receive BOTOX®
Cosmetic with the doctor. Be sure to list all medications, including nonprescription and alternative, which you are currently taking. There are
alternatives to Botox therapy for wrinkles, including no treatment, topical
cream treatments, chemical peels, laser peeling, surgical face lifting, and
surgical destruction of the muscles involved in the formation of dynamic
lines.
I understand and give permission for pictures to be taken of my
BOTOX® Cosmetic, both before and after treatment. I understand that
these photographs will remain the property of the clinic, and that they will
remain as part of my medical record. I also give permission for the use
of these photographs for teaching purposes, in lectures, in scientific
papers, journals, and books. My name will not be used with these
photographs.
Initial_____
Because BOTOX® Cosmetic for wrinkles is considered a cosmetic
procedure, insurance does not pay for treatment. Payment at the time of
service is required for all patients. You may request a price quote before
your treatment. We request a 48-hour notice of cancellation for all
scheduled Botox appointments.
By signing below, I agree that I have read and understand the above
information, and that my questions have been fully answered to my
satisfaction. I authorize Sarah de la Torre, MD to treat my wrinkles and
lines with BOTOX® Cosmetic. I understand that the practice of medicine
and surgery is not an exact science and that no results are guaranteed,
including BOTOX® Cosmetic for wrinkles and lines.
1st treatment __________
Patient
__________
Staff
_________
Date
_______
Fee
2nd treatment__________
Patient
__________
Staff
_________
Date
_______
Fee
3rd treatment__________
Patient
__________
Staff
_________
Date
_______
Fee
4th treatment__________
Patient
__________
Staff
_________
Date
_______
Fee
Juvederm Patient Informed Consent to Treat
Patient Name:______________________________
Date:_____________
Injectable Juvederm Ultra and Juvederm Ultra Plus Implants are gels of hyaluronic acid
generated by non animal protein. There is no necessity for skin testing prior to receiving
Juvederm treatment, as allergic reaction is very unlikely. Juvederm is indicated for implantation
into the mid to deep dermal layers of the skin in order to temporarily provide correction of
moderate to severe facial wrinkles and folds. Juvederm has been shown to provide correction
to the injected sites for up to 6 to 9 months; however, the correction does not last as long when
used for lip augmentation. Juvederm has not been studied for safety and effectiveness in
any other anatomic regions other than naso-labial folds and is not FDA approved for any
other sites other the nasal labial folds. Juvederm should not be used by patients with severe
allergies and with a history of anaphylaxis, pregnant or nursing, under the age of 18, in areas of
active infection, or on immunosuppressive therapy.
The risks involved in receiving Juvederm injections include very temporary inflammation at
injection site, demonstrated as redness, slight swelling, bruising, and tenderness and possibly
itching. If laser treatment, chemical peeling or any other procedure based on active dermal
response is considered after treatment, there is a possible risk of eliciting an inflammatory
reaction at the implant site. Without touch up injections, the correction will subside gradually
and your skin will look as it did before treatment. Patients using substances that reduce
coagulation, such as aspirin and non-steroidal anti-inflammatory drugs may experience
increased bleeding with resulting bruising at the injection sites. Other risks may include
temporary local pain, redness, and itching, temporary skin discoloration, bruising and swelling in
the treated area. Additional side effects are possible, but none have been observed or are
known of at this time.
You should contact your physician immediately should any unusual side effects occur.
As with any injection procedure, there exists the risk of side effects. These risks have been
explained to me in detail. I have read the above information and have had the procedure
explained to me by my doctor or his representative. I understand the success of this procedure
cannot be guaranteed and I am aware of the benefits and risks associated with this procedure.
I give my consent to treatment with Juvederm by Dr. de la Torre.
Patient Signature__________________________________
Date______________
MD’s Signature___________________________________
Date______________
Additional treatments:
Pt initials _______ Date_______
Pt initials _______ Date_______
Pt initials _______ Date_______
Pt initials _______ Date_______