Neurotoxin Consent

I consent to have my pictures and/or videos taken and stored in the electronic medical record system of Skyn Aura (the “Practice”). Such photographs and videos will not be used for any purpose except internal training without my express permission. I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment prior to receiving services. I further agree in the event of non-payment, cancellation of payment, or any payment issues, to bear the cost of collection and/or the court cost and legal fees. I consent to being signed up for the rewards programs so I can earn free points towards discounts on my treatments. I consent to email, text, and phone communications related to post-procedure care and follow-up appointments. I consent to receive promotional and marketing messages from Practice via email, phone, and SMS. I am not aware that I am pregnant. I am not trying to get pregnant. I am not lactating (nursing). I do not have or have not had any major illnesses which should prohibit me from receiving this treatment. I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to lidocaine. I am completely of sound mind and am fully aware of all the risks and possible complications of this procedure. I attest that I have not consumed any alcohol or other substance within the last 12 hours that would hinder my ability to consent to the procedure(s). I understand this procedure is voluntary. I have read the material given to me, and I am fully satisfied that all of my questions and concerns have been addressed. I understand that I am required to attend post-procedure check-ups as advised by Practice and that I am required to follow all post-treatment instructions. I have received and fully understand the pre-and post-treatment instructions. I have advised my provider of my medical history including all previous medical conditions and medications currently being taken by me. Alternatives to the procedures and options that I am choosing to have today have been fully explained to me. I consent to the administration of such anesthetics considered necessary or advisable. I understand that all forms of anesthesia involve risk and the possibility of complications and injury. I am aware that there may be other risks or complications not discussed or known that may occur. I also understand that during the course of the proposed procedure, unforeseen conditions may be revealed requiring the performance of additional procedures, and I authorize such procedures to be performed.I have the right to refuse any particular exam, test, treatment, or other intervention, with the understanding that doing so may affect the Practice’s ability to provide my care. I understand that appropriately supervised students, residents, and/or trainees may observe and assist in my care unless I expressly object.I understand that the Practice providers and staff treat all patients with dignity and respect, and the same is expected in return. There is a zero-tolerance policy for inappropriate, discriminatory, and/or threatening behavior. I acknowledge that no guarantees or promises have been made to me concerning the results of this procedure or any treatment that may be required as a result of this procedure. I understand there are no refunds and that multiple treatments are often required to achieve noticeable and lasting outcomes. I also understand that promotional items have no refund value. You have a right to be informed about your condition and its treatment, so that you may decide whether to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed, so you may give, or withhold, your consent for treatment.I voluntarily request that my provider at Skyn Aura (“Aesthetic Health Care Provider”) perform the neurotoxin procedure as indicated in my treatment plan. I understand that neurotoxins, such as Botox® Cosmetic, Dysport®, Jeuveau™, and Xeomin®, are FDA approved cosmetic injections for the temporary diminishment of muscle movement, resulting in an improvement in the appearance of fine lines and wrinkles to the treated area. I understand that neurotoxins, such as Botox®, have been approved by the FDA for the treatment of strabismus (crossed eyes), blepharospasm (eye twitching), chronic migraine headache, axillary hyperhidrosis (excessive sweating), cervical dystonia, and upper limb spacity. I understand that neurotoxins, such as Botox® Cosmetic, Dysport®, Jeuveau™, and Xeomin® have been approved for cosmetic treatment of the frown lines. Botox® Cosmetic® is also FDA approved for the treatment of crow’s feet and the frontalis (forehead). I understand that neurotoxins should not be used in individuals with known hypersensitivity to any ingredient in the formulation. I understand that “Off-label” use refers to the treating of any area of the face that is not approved by the FDA (e.g., bunny lines, jelly roll, jawline, asymmetry, lip border, gummy smile, chin dimpling, masseter, necklace lines, etc.) I understand that known significant risks have been disclosed in this consent, yet I understand that the theoretical risk of unknown complications also exists. I understand that the injection of neurotoxins 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 that the cosmetic purpose for being treated with neurotoxins is to decrease the wrinkles in the treated area. Due to the temporary nature of this treatment, re-injection is necessary within three to four months. In some cases, especially when being treated for the first time or by an Aesthetic Health Care Provider that does not have experience with you, a follow up treatment may be necessary to achieve the level of correction desired. It has been explained to me that other temporary and more permanent treatments are available. 

Risks and Side Effects: 

Swelling, infection, scarring, bruising, and allergic reaction Small bumps at the injection sites for a couple of hours to a few days. Headache for days to weeks (Botox® is approved for migraine headaches). Local numbness, rash, pain at injection site, flu like symptoms with mild fever, and back pain, Respiratory problems such as bronchitis, upper respiratory infections, sinusitis, nausea, dizziness, and tightness or irritation of the skin, Human albumin and transmission of viral diseases, Local weakness of the injected muscles in addition to weakness of adjacent muscles due to spread of the neurotoxin, Impaired or double vision, dry eyes, corneal exposure, and ulcerations, Difficulty swallowing (Dysphagia) and breathing difficulties, asymmetry.

Treatments: 

I understand more than one injection may be needed to achieve a satisfactory result. I will follow all aftercare instructions, as it is crucial I do so for healing. Should a complication arise, I agree to follow the recommendation of treatment by my health care provider at Skyn Aura.

As neurotoxins are not an exact science, there might be an uneven appearance of the face with some muscles more affected by the neurotoxins than others. In most cases, this uneven appearance can be corrected by injecting neurotoxins in the same or nearby muscles, however, in some cases this uneven appearance can persist for several weeks or months. I am not pregnant and I am not currently breastfeeding. I do not have any neurological diseases (e.g., myasthenia gravis, Lampert Eaton’s syndrome, etc.) or have any allergies to the toxin ingredients or to human albumin. The number of units injected is an estimate of the amount of neurotoxins required to decrease muscle movement. I understand I will be charged for subsequent treatments. No refunds will be given for treatments received. As with most medical procedures, there are risks and side effects. These have been explained to me in detail and my questions have been answered satisfactorily. I have read the above information and I give my consent to be treated. 

ARBITRATION AGREEMENT – READ CAREFULLY

It is understood and agreed by Practice and I, as a recipient of services, that any legal dispute, controversy, demand, or claim that arises out of or relates to the services provided to me by Practice or any other service provided by Practice to me shall be resolved exclusively by binding arbitration as provided by California law. It is understood that any dispute as to medical malpractice (whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompletely rendered) will be determined by submission to arbitration and not in a court of law or before a jury. It is the intent of the parties that this agreement covers all existing or subsequent claims or controversies, whether in tort, contract, or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to the treatment of services provided or not provided by any employee, physician, association, partner, or agent affiliated with Skyn Aura to a patient. I read, write, and fully understand English. I am of sound mind and body and have the full capacity to consent to this treatment.I hereby consent to the Neurotoxin Treatment and hereby authorize the Skyn Aura provider to perform the Neurotoxin Treatment.