Patient Information/Health History Form
Consent Form
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The purpose of this form is to provide you with written information regarding cosmetic injections, including possible risks and alternative treatment options.
Botulinum Toxin A is used to improve the appearance of moderate to severe facial expression lines (i.e. forehead, crow’s feet, and frown lines). These products take effect within 24 to 48 hours after being administered and the full effect is achieved after 7 to 14 days. On average, botulinum toxins last between 3 to 6 months.
Dermal filler are a stabilized hyaluronic acid gel that are used to correct moderate to severe facial wrinkles (laugh lines); contour facial features that have lost volume (tear troughs and cheeks); enhance lips; and improve recessed scars. These products produce a natural volume and results can often be seen immediately. On average, dermal fillers last between 6 to 9 months.
Bruising/Swelling: Common injection-related reactions may occur such as swelling, pain, discomfort, itching, discoloration, redness, bruising, or tenderness at the injection site. You may also experience increased bruising and bleeding at the injection site if you are taking non-steroidal anti-inflammatory drugs (i.e. aspirin, ibuprofen, and naproxen sodium). Please avoid anti-inflammatory drugs 2 weeks before treatment.
Headache: Transient headaches may occur after cosmetic injections. These are usually mild and last less than 24 hours. Headaches may be relieved with acetaminophen (Tylenol).
Allergies/Herpes Simplex Virus (HSV): Cosmetic injections should not be used in patients who have severe allergies and should not be used in areas with active inflammation or infection (i.e. cysts, pimples, herpes, rashes, or hives). Injections may also reactivate a dormant cold sore virus and trigger an outbreak. Valtrex prescriptions are available, upon request.
Eyebrow or Eyelid Ptosis (drooping) and Double Vision (diploma): Seen in 1.2% of patients receiving Botulinum Toxin A. This is temporary and usually lasts 2-4 weeks. Prescription eye drops are available, upon request.
Post-treatment bacterial, and/or fungi infection requiring further treatment may occur. Occasional numbness of the forehead may also occur and can last 2-3 weeks after treatment. Dermal fillers injected under the eye may also result in a weakened tear duct. Localized necrosis and/or sloughing, with scabs and/or without scabs can occur if blood vessel occlusion occurs. Other rare complications may include: granuloma formation and keloid formation/hypertrophic scarring (dermal filler treatments are not recommended for individuals who are susceptible to hyper-keloid formation).
Unsatisfactory Results: There is a possibility of a poor or inadequate response to cosmetic injections. Additional injections may be necessary. Unsatisfactory results may not improve with additional treatment.
Alternative treatments will vary by patient. Some patients may elect not to proceed with any form of treatment whatsoever. Others may explore skincare products, chemical peels, and/or skin resurfacing treatments to improve fine lines and wrinkles. Cosmetic surgery is another method of treatment and is considered the most aggressive, but permanent, solution.
If you have a history of neurological disease (i.e. ALS or Lou Gehrig’s disease, Myasthenia Gravis, or Lambert-Eaton syndrome) you may not be a candidate for cosmetic injections. This should be discussed with your treating neurologist or family physician prior to receiving treatment.
It is not recommended that you receive cosmetic injections if you are pregnant or nursing.
Cosmetic injections are considered an elective procedure and payment for all rendered services is the patient’s responsibility. Full payment is required at the time of service and it is non-refundable. If a touch-up treatment is required, the patient will also be responsible for the cost of additional service.
*I hereby affirm that I read and understand the forgoing informed consent and that my questions have been fully answered to my satisfaction. I consent to treatment with cosmetic injections and accept its associated risks. I hereby release Dr. Bloch and his employees from any liability associated with treatment.