Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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_______