Patient Health History Form
Name ___________________________________________________________
Date of Birth _______/_______/_______
Phone: (______) ______-_______
Email _______________________________________ How did you hear about us? ____________ Emergency Contact # ______________________________
Do you have any health problems or medical conditions? ___________________________________________________________________________________
Please list ALL allergies you may have (medicines, food, pollen, etc.) and briefly describe your reaction (i.e. rash, hives, shortness of breath, etc.). If no allergies,
please write NONE. ___________________________________________________________________________________________________________
Please list any medications, including prescription and over-the counter medicines, topical creams, facial skin care product and medicinal herbs you take:
___________________________________________________________________________________________________________________________
Please check the following:
Complications from any cosmetic procedures?
Form thick or raised scars from cuts or burns?
Any active infection?
Are you pregnant?
Any history of cold sores in the treatment area?
 NO
 NO
 NO
 NO
 NO
 YES
 YES
 YES
 YES
 YES
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the staff members of
my current medical or health conditions and to update this history. I hereby acknowledge that I have been presented with a copy of the Notice of Privacy Practice.
Signature ___________________________________________________ Date: ___________________________
STAFF ONLY
Area ________________________________
Discuss Risks and Benefit:
 NO  YES
Standard Preparation Protocol
 NO  YES
Botox: Lot # ___________________ Exp _______________ Total Units Used __________
Fillers: Sticker / # Syringe _____Anesthesia:___________ cc/inch used:_______ Lot #/ Exp:____________
Complications ___________________________________________________________
 NO  YES
Instruction Given Written and Verbally
 NO  YES
Notes:
I verify that this form is complete and correct.
Staff _______________________________
Date _______________________________
JUVEDERM INFORMED CONSENT
7.
Indications. Juvederm® is a sterile gel consisting of stabilized hyaluronic acid; Allergan, the manufacturer, states that it
is biodegradable, and safely and completely metabolized by the body. Juvederm® injections are given to correct facial
wrinkles and/or for lip augmentation. Juvederm® has been approved by the FDA (Food and Drug Administration) for
correction of facial wrinkles in the nasolabial area (nose-lips) and the fold between the cheek and the nose/upper lip (“onlabel” use). I understand that the safety and effectiveness of treating facial areas other than the nasolabial folds has not
been studied. This “off-label” aspect of the treatment has been explained to me.
Results. I understand that the actual degree of improvement cannot be predicted or guaranteed. Furthermore, I
understand that the effect will gradually wear off and additional treatments may be necessary to maintain the desired
effect. I understand that treatments can last anywhere from 4-6 months up to one year. I understand that more than one
injection may be needed to achieve a satisfactory result.
Risks and Complications
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, bruising, discoloration, tenderness, and itching (These symptoms are
usually mild and typically last a few days but can last up to a few months. In rare cases, bruising can last several months
and even be permanent.)
2) Post treatment bacterial, viral and/or fungal infection associated with any transcutaneous injections which in most
cases are easily treatable but in rare cases a permanent scarring in the area can occur.
3) Allergic reaction. As with any product, allergies can develop during or after injection.
4) Injection into the lip area could cause recurrence of Herpes simplex ( facial cold sores) for patients with a history of
prior cold sores.
5) Lumpiness, visible yellow or white patches in approximately 20% of cases
6) Granuloma formation
7) Localized Necrosis and/ or sloughing, with scab and/or without scab if blood vessel occlusion occurs.
8) Scarring
Precautions and contraindications
Due to the potential for an allergic reaction, Juvederm® is not recommended for patients with severe allergies or a history
of anaphylaxis. The risk of bruising or bleeding may be increased by medications with anticoagulant effects, such as
aspirin and non-steroidal anti-inflammatory drugs (e.g., Ibuprofen, Aleve, Motrin, Celebrex), high doses of Vitamin E,
and certain herbs (Ginkgo Biloba, St. John’s Wart). The safety of Juvederm® in pregnant or breast-feeding women has
not been established, and is therefore not recommended for these women.
Consent
I understand the need for local anesthesia to reduce the discomfort of the procedure and consent to the topical application
of anesthetic gel and/or injections for a nerve block or local infiltrative anesthesia. I understand the above, and have had
the risks, benefits, and alternatives explained to me, and have had the opportunity to ask questions. No guarantees about
results have been made. To the best of my knowledge, I am not pregnant, and I am not breastfeeding. I give my
informed consent for Juvederm® injections today as well as future treatments as needed. If you are under 18 years of age
we require a signature of a parent or legal guardian.
I will follow all aftercare instructions as it is crucial for proper healing to take place.
By signing below, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its
associated risks. I hereby give consent to perform this and all subsequent Juvederm® treatments with the above
understood. I hereby release the doctor, the person injecting the Juvederm® and the facility from liability associated with
this procedure.
8.
BOTOX COSMETIC INFORMED CONSENT
I understand that I will be injected with Botulinum A Toxin (Botox) in the area of the glabella muscles to paralyze these
muscles temporarily or in the forehead or crows feet around the lateral area of the eyes. Botulinum A Toxin (Botox)
injection has been FDA approved for use in the cosmetic treatment for glabellar frown lines only – the wrinkles between
the eyebrows. Injection of Botox into the small muscles between the brows causes those specific muscles to halt their
function (be paralyzed), thereby improving the appearance of the wrinkles. I understand the goal is to decrease the
wrinkles in the treated area. This paralysis is temporary, and re-injection is necessary within three to four months. It has
been explained to me that other temporary and more permanent treatments are available.
1.
2.
3.
4.
5.
6.
Risks: I understand there is a risk of swelling, rash, headache, local numbness, pain at the injection site, bruising,
respiratory problems, and allergic reaction.
Infection: Infections can occur which in most cases are easily treatable but in rare cases a permanent scarring in the
area can occur.
Most people have lightly swollen pinkish bumps where the injections went in, for a couple of hours or even several
days.
Although many people with chronic headaches or migraines often get relief from Botox, a small percent of patients
get headaches following treatment with Botox, for the first day. In a very small percentage of patients these
headaches can persist for several days or weeks.
Local numbness, rash, pain at the injection site, flu like symptoms with mild fever, back pain.
Respiratory problems such as bronchitis or sinusitis, nausea, dizziness, and tightness or irritation of the skin.
9.
10.
11.
Bruising is possible anytime you inject a needle into the skin. This bruising can last for several hours, days, weeks,
months and in rare cases the effect of bruising could be permanent.
While local weakness of the injected muscles is representative of the expected pharmacological action of Botox,
weakness of adjacent muscles may occur as a result of the spread of the toxin.
Treatments: I understand more than one injection may be needed to achieve a satisfactory result.
Another risk when injecting Botox around the eyes included corneal exposure because people may not be able to
blink the eyelids as often as they should to protect the eye. This inability to protect the eye has been associated with
damage to the eye as impaired vision, or double vision, which is usually temporary. This reduced blinking has been
associated with corneal ulcerations. There are medications that can help lift the eyelid, however, if the drooping is
too great the eye drops are not that effective. These side effects can last for several weeks or longer. This occurs in
2-5 percent of patients.
I will follow all aftercare instructions as it is crucial I do so for healing.
As Botox is not an exact science, there might be an uneven appearance of the face with some muscles more affected by
the Botox than others. In most cases this uneven appearance can be corrected by injecting Botox in the same or nearby
muscles. However in some cases this uneven appearance can persist for several weeks or months. This list is not meant
to be inclusive of all possible risks associated with Botox as there are both known and unknown side effects associated
with any medication or procedure. Botox should not be administered to a pregnant or nursing woman. Additionally, the
number of units injected is an estimate of the amount of Botox required to paralyze the muscles. I understand there is no
guarantee of results of any treatment. I understand the regular charge applies to all subsequent treatments.
My questions regarding the procedure have been answered satisfactorily. By signing below, I acknowledge that I have
read the foregoing informed consent and agree to the treatment with its associated risks. I hereby give consent to perform
this and all subsequent Botox treatments with the above understood. I hereby release the doctor, the person injecting the
Botox and the facility from liability associated with this procedure.
LOCAL ANESTHESIA INFORMED CONSENT FORM
Local anesthesia is a technique that allows control of your pain during and after
procedure. A local anesthetic solution is injected close to nerve fibers to block the transmission of pain. This will result
in numbness and in some cases also in inability to move the anesthetized area below the puncture point. This technique is
also called a “Block”. After inserting a specific needle through the skin the nerve is located. A local anesthetic will then
be injected and it will take approximately 10 to 15 minutes before you feel numbness in the anesthetized area. Local
anesthesia is a well-established and safe technique. In addition, all blocks are performed by, or under the supervision of
experienced attending physicians. However, like with any other medical intervention there is a small risk of potential side
effects:
Allergic reactions: Please let us know if you are known to be allergic to a local anesthetic. Allergic reactions seldom
occur, reason why this technique can be recommended if you have a high level of
allergies or asthma.
Nerve injury: An injury to the nerve can be caused while the block is performed. If it ever happens, you might experience
a transitory sensory deficit or paresthesia (tingling) in a part of the anesthetized area. This sensation will usually
disappear within a few days.
Seizures: If a local anesthetic is injected directly into a blood vessel or a very large dose of a local
anesthetic is injected, a seizure can occur. To avoid this potential complication, we assure
correct needle placement before the local anesthetic is injected. In addition, we will never
exceed the maximal recommended dose of the local anesthetic.
Hematoma: A small hematoma or bruise can develop at the site where the needle was inserted. This
will usually resolve within a few days.
Infection: Sterile techniques are used when a block is performed. However, there is a very small
risk of infection, especially when a catheter is placed to provide long-term pain relief.
My questions regarding the procedure have been answered satisfactorily. By signing below, I acknowledge that I have
read the foregoing informed consent and agree to the treatment with its associated risks. I hereby give consent to perform
this and all subsequent treatments with the above understood. I hereby release the doctor, the provider and the facility
from liability associated with this procedure.
I have received and understand the pre /post care instructions.
I understand that all injections will be performed by trainees (practitioner who are currently learning).
Print Name __________________________________
___________________________
Patient Signature
Date
Cosmetic Filler Pre and Post
BOTOX® COSMETIC Pre and Post
Skin filler treatment involves the injection of highly purified, individualized doses of hyaluronic
acid (Restylane and Juvederm) into unwanted skin folds, creases, lines, and wrinkles. The skin
filler acts by superficially “filling” in and simply smoothing out unwanted skin lines with a
biologically natural product. The procedure must be performed by an appropriately licensed and
trained physician or mid-level provider pursuant to physician supervision and according to
prevailing state law. The following Self-Care instructions have been developed specifically for
our patients.
Botox® cosmetic treatment involves the injection of highly diluted, individualized doses of
botulinum toxin A into (or in close proximity to) overactive facial muscles or sweat glands, which
are responsible for wrinkles or excessive sweating respectively. Botox® relaxes muscle(s)
and/or sweat glands by diminishing their ability to contract. The procedure must be performed
by an appropriately licensed and trained physician or mid-level provider pursuant to physician
supervision and according to prevailing state law. The following Botox® injection Self-Care
instructions have been prepared specifically for our patients.
BEFORE TREATMENT
For one week before treatment, please avoid the following medications: Aspirin, Advil, Motrin,
Ibuprofen, Aleve, Naprosyn, Excedrin (all OTC pain pills except Tylenol), Vit. E, Vit.A (RetinA,
Renova, Tretinoin, Tazorac, Differin, Triluma), Gingko Biloba, Omega-3 fatty acids, cod liver oil,
CoQ10, garlic and ginger.
If you are taking any blood-thinning medications as per doctor’s orders (such as Coumadin,
Warfarin, Plavix, Lovenox),do not discontinue without first consulting the prescribing physician. If
you continue to take these medications the chances of developing an injection-related
hematoma (blood clot) which can leave a dark spot if it becomes entrapped in the filler implant is
higher. The dark spot may remain until the filler is naturally dissolved.
Do not schedule any social events for the next 3-7 days as you may have bruising and/or
swelling lasting this long or longer. You can cover up bruising with makeup.
Arrive for your appointment wearing no makeup if possible. You will be able to apply makeup
after your treatment although we recommend waiting at least 24 hrs.
BEFORE TREATMENT

For one week before treatment, please avoid the following medications: Aspirin, Advil,
Motrin, Ibuprofen, Aleve, Naproxen, Excedrin (all OTC pain pills except Tylenol),
vitamin E, Vitamin A (Tretinoin, Retin-A, Renova, Differin, Tazorac, Triluma), Gingko
Biloba, Omega-3 fatty acids, cod liver oil, CoQ10, garlic and ginger.

Avoid sun exposure to the area to be treated one week before treatment.

Do not take ANY muscle relaxing medications (example: Soma or Flexaril) at least
one month before treatment.
AFTER TREATMENT
Keep the treated areas clean. Light make-up coverage is acceptable if desired.
You may apply ice for 5 minutes every 1⁄2 hour if there is any pain or swelling. Any bruising will
eventually resolve on its own, typically within one to two weeks.
If post-injection bruising is noticed, consider using the OTC homeopathic natural remedy Arnica
Montana, which has been shown to rapidly relieve and even prevent bruising. Arnica is
available at most health food stores and is safe (free of reported side-effects).
As always, wear at least SPF 30 sun block when appropriate and try to avoid exposure to
intense, direct sunlight & heat (example: sun lamp steam, sauna) for at least two to three days.
Do not take aspirin containing products (see above) for the next 24 hours. These agents may
increase bruising/bleeding at the injection site. Again, Tylenol may be taken.
Avoid alcohol intake beyond a single drink, glass of wine, or beer for approximately 24 hours
after treatment. You may sleep with an extra pillow if desired to minimize swelling overnight.
As always, tobacco and illicit drugs are discouraged.
Discontinue Retin-A (Tretinoin) for 3-5 days after treatment. It is best to wear no makeup or
lipstick until the next day. Earlier use can cause pustules.
One side may heal faster than other side. You may have bumps or nodules of filler under the
skin that can last 4-8 months after the injection. If they are particularly troublesome you can
massage them, we can also give a small injection to help dissolve them faster.
If there is any leftover product, it must be used within 2 weeks of opening to avoid
contamination.
Keep in mind that evidence shows that having a follow-up treatment before the product has fully
dissipated tends to enhance the lasting effect of skin fillers.
Wait at least a week (preferably 2-3 weeks) after your injection before having other procedures
done in the same anatomic area; example: microdermabrasion, laser treatment, chemical peel,
etc.
Please notify us with any further concerns/questions. Note that you can optionally schedule a
follow-up visit to evaluate results after the initial swelling has dissipated. Typically hyaluronic
fillers can be reshaped for up to two weeks post-injection.
AFTER TREATMENT

Remain upright for 6 hours following treatment. No lying down or bending over.

Keep the treated areas clean. Light make-up coverage is acceptable if desired.

You may apply ice for 5 minutes every 1⁄2 hour if there is any pain or swelling. Any
bruising will eventually resolve on its own, typically within one to two weeks.

If post-injection bruising is noticed, consider using the OTC homeopathic natural
remedy Arnica Montana, which has been shown to rapidly relieve and even prevent
bruising. Arnica is available at most health food stores and is safe (free of reported
side-effects).

As always, wear at least SPF 30 sun block when appropriate and avoid exposure to
intense, direct sunlight and heat (example: sun lamp steam, sauna) for at least two to
three days.

Move the facial muscles (frown, smile, raise eyebrows) that have been treated
throughout the rest of the day. This will help the muscles absorb the Botox®
Cosmetic.

Avoid vigorous exercise for 24 hours.

Do not rub or massage the areas treated for 24 hours.

Do not take aspirin containing products (see above) for the next 24 hours. These
agents may increase bruising/bleeding at the injection site. Again, Tylenol may be
taken. Discontinue RetinA (Tretinoin) for at least 3-5 days after treatment.

Avoid alcohol intake beyond a single drink, glass of wine, or beer for approximately 24
hours after treatment.

As always, tobacco and illicit drugs are discouraged.

The onset of muscle relaxation usually begins in 7-10 days, but optimal results may
take up to 2 weeks.

*NOTE*: Results may vary. If there is partial improvement of a treated site, and retreatment is desired, a second treatment may be performed no sooner than 2 weeks
after the primary treatment. There is a subsequent charge for any “touch–up’s” or
additional treatment.

Please contact us should there be any side effects or questions regarding your
treatment with Botox® Cosmetic.