U&I Spa Inc

Botox & Dermal Fillers Consent Form

130 West 57th Street, Suite 14A
New York, NY, 10019
Phone: 917.214.9910
Email: uandispa@gmail.com

Please answer all questions below and press the [SUBMIT] button on all forms.

1. PERSONAL INFORMATION

2. INFORMATION ABOUT PROCEDURES

ABOUT BOTOX

Injection of BOTOX (botulinum toxin) causes weakness of targeted muscles, which can last approximately 2-4 months and over this time the effects will diminish. Injection of small amounts of botulinum toxin relaxes the treated muscles and can reduce facial wrinkles such as frown lines. It is injected with a small needle into the targeted muscles. Effects are typically seen in a few days and can take 1-2 weeks to fully develop.

Possible risks, side-effects, and complications with BOTOX include but are not limited to:

● Localised burning or stinging pain during injection
● Blepharoptosis (droopy eyelid)
● Eyebrow ptosis (droopy eyebrow)
● Ectropian of the lower eyelid (eyelid margin eversion)
● Lagophthalmus (incomplete eyelid closure)
● Xerophthalmia (dry eyes)
● Epiphora (excess tearing)
● Diplopia (double vision)
● Impaired blink reflex
● Photophobia (light sensitivity)
● Globe trauma
● Infraorbital festooning (worsening of eyebags)
● Lip ptosis with resultant smile asymmetry
● Oral incompetence with resultant drooling and impaired speaking, eating or drinking
● Cheek flaccidity
● Dysarthria (difficulty articulating)
● Dysphagia (difficulty swallowing)
● Hoarseness
● Neck weakness
● Facial asymmetry, alteration or poor aesthetic result
● Inadequate reduction of wrinkles or lack of intended effect in the treatment area
● Worsening wrinkles in areas adjacent to the treatment area
● Weakening muscles adjacent to the treatment area
● Autoantibodies against botulinum toxin. Autoantibodies may be present or develop after injection, rendering treatments ineffective (1-2% of patients treated for cosmetic indications)
● Extremely rare, immediate hypersensitivity reaction with signs of urticaria, oedema and a remote possibility of anaphylaxis
General Injection-related complications (can be any treatment):
● Pain
● Bruising
● Erythema
● Oedema
● Tenderness
● Headache
● Infection
● Numbness or paresthesia
● Anxiety
● Vasovagal episode and loss of consciousness
● For most complications there are no corrective treatments and they spontaneously resolve as botulinum toxin effects diminish.

WHAT NOT TO DO BEFORE BOTOX:


1. Drink Alcohol
Doctors often advise that patients should avoid eating or drinking anything 12 to 24 hours before a surgical procedure. While Botox doesn’t require you to stay away from food, avoiding alcohol before Botox is highly recommended. The main reason for this is that alcohol tends to thin the blood, increasing the risk of bruising and bleeding. It also dries the skin, making Botox treatment less effective.

2. Drink Coffee
You should also avoid coffee before Botox. This is because coffee contains caffeine, which may trigger your blood pressure and increase the likelihood of bruising during the procedure. For this reason, you should avoid coffee and other beverages containing caffeine at least 24 hours before the treatment.

3. Use Topical Products
Some topical products such as Retin-A, Retinols, Glycolic Acid, Retinoids, and Alpha Hydroxy Acid may break your skin, making you susceptible to bruises and infections after the procedure. You should stay away from topical products starting three days before Botox treatment. If you have sensitive skin or a history of perioral herpes, you should start antiviral therapy days before treatment so that the medication doesn’t react to Botox.

4. Waxing, Bleaching, or Tweezing
Another precaution that you should take is to avoid bleaching, waxing, or tweezing the area to be treated. You should also avoid using depilatory creams near the area to be treated for one or two days prior to Botox treatment.

5. Take Aspirin or Blood-Thinning Medications
You’ll need to stop taking blood-thinning medications such as ibuprofen, Excedrin, and aspirin before Botox. Remember to ask your doctor before stopping your medications. In some cases, you may need to consider rescheduling your Botox treatment until you finish your dosage.

ABOUT DERMAL FILLERS

Dermal fillers are used for the treatment of facial creases, wrinkles, folds, contour defects, depression scars, facial lipoatrophy (loss of fat) and enhancement purposes. These treatments involve multiple injections of filler into or below the skin to fill wrinkles and restore volume. The effects of dermal fillers are temporary and no guarantees can be made regarding how long correction will last in a specific patient. Alternatives to temporary fillers include, but are not limited to: permanent dermal fillers, laser resurfacing and skin tightening, surgical facelift or no treatment at all.

Possible risks, side-effects, and complications with dermal fillers include but are not limited to:

● Bruising, redness and swelling
● Visible raised areas or bumpiness at/around the treated site
● Asymmetry, over correction or under correction.
● Unpredictable persistence of filler, either shorter or longer than anticipated
● Prolonged discolouration of the skin such as brown, greyish, bluish or reddish colouration.
● Filler material may be extruded from the skin in rare cases
● Prolonged or severe swelling
● Infection
● Rarely granulomas or firm nodules may form
● Benign tumour formation (keratoacanthomas)
● Allergic reaction with itchiness, redness and in extremely rare cases generalised allergic response such as a whole body swelling, respiratory problems and shock
● Scarring is extremely rare
● Skin breakdown or ulceration
● Tissue necrosis is extremely rare
● Blindness

WHAT NOT TO DO BEFORE DERMAL FILLERS:


One Week Prior to Lip Injections:

Avoid blood thinning over-the-counter medications such as aspirin, Motrin, ibuprofen, and Aleve.
Avoid supplements, including St. John’s Wort, Gingko biloba, primrose oil, garlic, ginseng, and Vitamin E.

2 Days Prior to Injections:

Avoid topical products such as Tretinoin (Retin-A), Retinol, Retinoids, Glycolic Acid, or any “anti-aging” products.
Avoid waxing, bleaching, tweezing, or using hair removal cream on the area to be treated.
Do start taking Arnica two days prior to the procedure. (This is not required, but it will help to lessen bruising.)

24 Hours Prior to Injections:

Do not drink alcoholic or caffeinated beverages 24 hours prior.

General Recommendations:

If you have previously suffered from facial cold sores, there is a risk that the needle punctures could contribute to another eruption of cold sores. Please let your physician assistant know if you are prone.
Do not use dermal fillers if you are pregnant or breastfeeding, are allergic to any ingredients, or suffer from neurological disorders. Please inform us if you have any questions about this prior to your treatment.

PLEASE CONTACT US IMMEDIATELY IF YOU:


Have fever and/or chills
Have discolored blotches in areas not injected
Have blanching of injected areas
Notice the area appears red and/or hot to the touch
Have severe or increasing pain

3. MEDICAL HISTORY

*Do you have any of the following?

4. PLEASE SELECT ANY THAT APPLY TO YOU

5. CLIENT SIGNATURE

Consent: My consent and authorization for this elective procedure is strictly voluntary. By signing this informed consent form, I hereby grant authority to Cosmetologist Fanuza Gareeva to perform Botox or Dermal Filler injection to area(s) discussed during our consultation that are listed here.

My signature below certifies that I have fully read this consent form and understand the written information provided to me regarding the proposed procedure. I have been adequately informed about the procedure including: the potential benefits, risks, limitations and alternative treatments and I have had all questions answered to my satisfaction.

Please note audiovisual recordings may be taken for records. I have read this informed consent and hereby certify that I understand its contents in full. I understand that medicine is not an exact science and acknowledge that no guarantee has been given or implied by anyone as to the results that may be obtained by this treatment. I also understand this procedure is “elective” and not covered by insurance and that payment is my responsibility. Payment in full for all treatments is required at the time of service and is non-refundable.

The client indicated below also agrees to forever hold harmless and release from any and all liability, claims, or demands of any kind or nature related to the transmission of any disease, condition or illness including but not limited to COVID-19 they may allege to have contracted or been exposed to as the result of any treatment, person, or visit to U&I Spa Inc.