Dysport/Botox
Name _______________________________________________________________________________________ Date of Birth ________________________________
Address____________________________________________________________ City ________________________________State _________ Zip ________________
Home Tel. # __________________________________________________________________ Cell # _____________________________________________________
Email _______________________________________________________________________How Referred _______________________________________________
Are you on an aspirin regimen? Y / N
Do you take any blood thinning medications? Y / N
Have you previously had cosmetic injectables? Y / N
Do you have a neuromuscular disorder? Y / N
Are you allergic to botulinum? Y / N
Are you pregnant or nursing? Y / N
Dysport / Botox Cosmetic is a synthetically produced substance that inhibits nerve activation of muscles after its application. The purpose of this treatment is to
prevent skin lines associated with underlying muscle movement, often referred to as “dynamic wrinkles”. After 3-14 days, the effects of this treatment can be fully
seen and these effects may last 3-6 months depending on the area(s) of treatment.
While temporary, complications are uncommon, the following potential side effects may occur with Dysport / Botox Cosmetic administration:
-
Temporary bruising or redness at the injection site.
Allergic reaction to the product.
Migration of the injected material causing an undesired cosmetic effect including eyelid weakness or weakness to other facial muscles around
injection site which is temporary.
Due to the uncertainty of its effect in humans at routine treatment doses, you should not receive Dysport / Botox treatments if you are pregnant. Dysport / Botox
Cosmetic should be avoided in patients with known neuromuscular disorders or those taking certain antibiotics.
I consent to this procedure. I understand no promise of results have been made to me by Nu-Skin Laser Solutions, Nu-Skin Laser Solutions Too, Dr. BenincasaFeingold, representatives or staff. I agree to inform the provider of any changes in my skin after treatment as well as changes in my general health. I hereby
release Nu-Skin Laser Solutions, Nu-Skin Laser Solutions Too, Dr. Benincasa-Feingold, representatives, staff and the specific technician from any liability with
the above. I have been given a copy of this form. By signing below, I certify the above information to be accurate.
__________________________________________________________________________________________________________
Signature
Date
What to expect after Dysport / Botox Injections
-
The injected area may be tender to touch for a few days. Some individuals may experience a vague temporary
headache when the entire forehead is treated. Tylenol may be taken as needed.
Do not massage the injected areas for 72 hours.
You may wash your face and apply make-up as directed.
Do not rigorously exercise for 24 hours.
No bending or heaving lifting for 4 hours.
No lying down flat for 4 hours.
Avoid sun exposure and alcoholic beverages for up to 48 hours.
The effect of the Dysport / Botox injection will not be noticeable for 48 to 72 hours. It may take a week for the full
effect to be appreciated. If the desired effect is not apparent two weeks after you have had the injections please call.
Sometimes, additional Dysport / Botox is necessary.
The effects of Dysport / Botox injections can last two four months.
For a medical emergency related to your injection(s), please call the office.
I received a copy of this form for my records
Patient Name: ________________________________________________________________
Patient Signature: ________________________________________ Date: ________________
HIPAA Privacy Authorization Form
**Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R.Parts 160
and 164)**
Dear Patient/ Family Member:
This is to inform you that there are new HIPAA laws that have gone into effect.
Additionally, this is to inform you that a copy of the HIPAA is available upon request and a copy of the HIPAA is also
displayed at our office.
Please read over and sign below, verifying that you are aware of your HIPAA rights as outlined above and that you grant
permission to acknowledge you as a client for referral and appointment scheduling purposes only.
If you have any questions, please contact the office at (845) 337-1125.
Photographs
I agree to have my photographs taken for proof of medical documentation.
_____ I DO authorize use of my image for purposes other than medical documentation
_____ I DO NOT authorize use of my image for purposes other than medical documentation
________________________________________________
Patient Name - PRINTED
_____________________________
Date
________________________________________________
Person Responsible for Patient - SIGNATURE
_____________________________
Date
________________________________________________
Nu-Skin Laser Solutions Representative
_____________________________
Date
Dysport / Botox Cosmetic is a synthetically produced substance that inhibits nerve activation of muscles after its application. The purpose of this treatment is to
prevent skin lines associated with underlying muscle movement, often referred to as “dynamic wrinkles”. After 3-5 days, the effects of this treatment can be fully
seen and these effects may last 3-6 months depending on the area(s) of treatment.
While temporary, complications are uncommon, the following potential side effects may occur with Dysport / Botox Cosmetic administration:
-
Temporary bruising or redness at the injection site.
Allergic reaction to the product.
Migration of the injected material causing an undesired cosmetic effect including eyelid weakness or weakness to other facial muscles around
injection site which is temporary.
Due to the uncertainty of its effect in humans at routine treatment doses, you should not receive Dysport / Botox treatments if you are pregnant. Dysport / Botox
Cosmetic should be avoided in patients with known neuromuscular disorders or those taking certain antibiotics.
I consent to this procedure. I understand no promise of results have been made to me by Nu-Skin Laser Solutions, Nu-Skin Laser Solutions Too, Dr. BenincasaFeingold, representatives or staff. I agree to inform the provider of any changes in my skin after treatment as well as changes in my general health. I hereby
release Nu-Skin Laser Solutions, Nu-Skin Laser Solutions Too, Dr. Benincasa-Feingold, representatives, staff and the specific technician from any liability with
the above. I have been given a copy of this form. By signing below, I certify the above information to be accurate.
What to expect after Dysport / Botox Injections
-
The injected area may be tender to touch for a few days. Some individuals may experience a vague temporary
headache when the entire forehead is treated. Tylenol may be taken as needed.
Do not massage the injected areas for 72 hours.
You may wash your face and apply make-up as directed.
Do not rigorously exercise for 24 hours.
No bending or heaving lifting for 4 hours.
No lying down flat for 4 hours.
Avoid sun exposure and alcoholic beverages for up to 48 hours.
The effect of the Dysport / Botox injection will not be noticeable for 48 to 72 hours. It may take a week for the full
effect to be appreciated. If the desired effect is not apparent two weeks after you have had the injections please call.
Sometimes, additional Dysport / Botox is necessary.
The effects of Dysport / Botox injections can last two to four months.
For a medical emergency related to your injection(s), please call the office.
I received a copy of this form for my records
CLIENT COPY