Procedure Informed Consent - New Medical Spa

Body Contouring

BODYSCULP Is for treatment of unwanted fat in patients with a BMI of less than 30. I agree to massage the treated area for five minutes five times per day for five days. I consent to regular monthly treatments. Unwanted effects include poor cosmetic outcome, pain, blistering, changes in skin color, stinging and infection.

Microneedling

Is used with radiofrequency for skin rejuvenation. I agree that I do not have any metal or electronic implants under the skin. Possible risks include poor cosmetic outcome, changes in skin texture or color, scarring, pain, blistering. I consent to regular monthly treatments

Microneedling may be used with PRP from my own blood for skin rejuvenation or hair loss. Multiple treatments are needed. Side effects include, but are not limited to those listed below.

RFMN
For skin rejuvenation. I agree that I do not have any metal or electronic implants under the skin. Possible risks include poor cosmetic outcome, changes in skin texture or color, scarring, pain, blistering

Botox

BOTOX(Used interchangeably for any brand of Botulinum Toxin) Improves wrinkles by causing muscles to decrease function or become paralyzed 2 weeks after treatment. This decrease in muscle function is temporary and should be repeated in 2 months. I consent to treatments regularly, every few weeks to months. Weakness of adjacent muscles may occur because of the spread of the botulism.Side effects include, but not limited to, those listed below as well as: temporary ptosis; lid changes; corneal exposure, resulting in impaired or double vision (which is usually temporary); reduced blinking (associated with corneal ulcerations).
An auto renewable membership may be purchased.

Dermal Filler

HA, CAHA, PMMA, COLLAGEN, PLLA

For facial counturing or diminishing the appearance of wrinkles. Lasts up to 6 months or longer. I consent to regular ongoing treatments every several weeks to months. By signing this consent form, I am confirming that I not have severe allergies, particularly allergies to bacterial proteins, which precludes treatment. Hyaluronidase may be used “off label” to smooth out an unfavorable result of Dermal Filler; or to treat an adverse reaction such as vascular occlusion. In the case of vascular occlusion, the risk of tissue necrosis or blindness cannot be completely removed. I consent to treatment, without skin allergy testing, with hyaluronidase if there is a suspected vascular occlusion.

Bellafill®

Bellafill is indicated for the correction of nasolabial folds and moderate to server, atrophic, distensible facial acne scars on the cheek in patients over the age of 21 years. Bellafill is an FDA-approved dermal filler made of sterile polymethylmethacrylate ( PMMA ) microspheres in a purified bovine collagen gel carrier. I consent to regular ongoing treatments every several months. I do not have severe allergies and agree to treatment with Bellafill without a skin allergy test.

KYBELLA & PCDC

Improves submental fat, “double chin.” Multiple monthly treatments are required. Side effects include, but are not limited to: nerve injury, causing uneven smile or facial muscle weakness (usually self-limited); temporary trouble swallowing (likely due to neck swelling); skin erosions; hair loss; more noticeable platysma bands; visual deformities.
I consent to the use of Kybella “off label” in the treatment of body fat; and PCDC in the treatment of submental (chin) fat and body fat. It has been explained to me and I understand that PCDC is not FDA approved for any indication and may result in tissue cavitation or fat embolism, which can cause organ damage. I consent to regular ongoing monthly treatments

MIC B12

Increases energy and aids in weight management. Supplements or medicine may cause side effects when used with MIC B12. I consent to regular ongoing weekly treatments. An auto renewable membership membership may be purchased.

CHEMICAL PEEL

I consent to regular, monthly chemical peels.

PDO THREAD LIFT

Used to soften wrinkles,lift and tighten skin, and stimulate collagen production. Lasts up to 2 years. Risk/side effects, in addition to those listed below, include partial: correction requiring re-treatment; scarring; visible threads; irregularity or dimpling of skin; hematoma; pigment changes to skin; neuropraxia, or damage to deeper structures of the face. Threads may extrude and may have to be trimmed or removed in the future. PDO Thread Lift is contraindicated in patients with cutaneous neurofibromatosis, excoriation disorders, allergy or foreign body a sensitivities to plastic biomaterials, or existing implants in the area of treatment. I consent to repeat thread lifts as needed.

LASER SERVICES

Laser therapy is not recommended if any of the following conditions exist: pregnancy, nursing, photosensitivity disorder, immunosuppressive disease, diabetes, bleeding disorder, seizure disorder triggered by light, active herpes, active shingles, or any active infection. I will notify my treating clinician if I have any of these conditions. Laser hair removal is not recommended for individuals who have used Accutane within the last six months or who used medications requiring limited exposure to sunlight.It should be understood that laser treatments may need to be repeated several times before complete satisfaction is achieved. No guarantees have been made to me regarding the outcome of the treatment or any improvements in my condition due to the procedure.
Possible Risks:

Pain, burning, blister formation, and stinging sensation at the site of treatment.
Infection associated with the treatment site.
Pigmentary (color) changes at the treatment sites including a decrease in skin color (hypopigmentation or lightening) and/or increase in skin color (hyperpigmentation or darkening).
Scar formation at the treated site.
Laser-induced “cold sore like” blistering skin eruptions known as “herpetic” skin eruptions at the treatment site or surrounding tissue.
Poor cosmetic outcome.
Recurrence of vessels at the treated sites.

ULTHERAPY

Results may take up to six months to be visible. Subsequent treatments may be necessary at full value to achieve desired results. I consent to regular, monthly treatments as needed.Risks include redness, swelling , bruising, burning, scarring, numbness, and weakness.

PRO-NOX

Possible risks include: headache, euphoria, decreased mental and physical awareness and control, dizziness, nausea, and unsteadiness. I consent to regular, monthly treatments as needed.Patients should wait 10 minutes after the last use of PRO-NOX before driving a car or operating any type of machinery.

MEDICATIONS

Upneeq
Upneeq is indicated for acquired eyelid sag. It may cause eye irritation, dryness, blurry vision, or headache. It should not be used if you have a history of cardiovascular disease, abnormal blood pressure, stroke, or cerebral aneurysm. It may increase risk of glaucoma.

Latisse
Latisse is indicated to treat thinning eyelashes. It may cause irritation or pigmentation on the area treated; therefore should not go into the eye. It should not be used in patients who are being treated for glaucoma.

Semaglutide

Semaglutide, when used with proper nutrition and exercise, helps with blood, sugar, control, and weight management. I do not have a family history or personal history of thyroid, cancer. I do not have diabetes, pancreatic, kidney, or gallbladder disease; mental illness including depression, and suicidal thoughts.

I have shared my medical history and meditations with my provider.

I am not pregnant or breast-feeding.

To my healthcare provider, I will report any episodes of abdominal pain, allergic reaction, increased, heart rate, depression, or suicidal thoughts.

I understand “there is a significant risk of nausea and vomiting, for which I may take prescription medication if needed”

CONSENT FOR TREATMENT

CONSENT FOR TREATMENT 1(Required)

I understand that all of the above treatments carry risks including, but not limited to: infection, pain, swelling, asymmetry, scaring, allergic reactions, cold sores, headache for weeks, nodules, bumps, rash, bleeding, burning, tightness, nausea, dizziness, blindness, permanent bruising, diarrhea, upset stomach, warmth, feeling of numbness or swelling of entire body or some areas, rapid heartbeat, chest pain, flushing cramps hives, and breathing problems. I understand that the art of cosmetic injection and aesthetic treatments is not an exact science; that touchups may be needed at full cost; and there is no guarantee of results. I consent to touch up treatments and to regular, ongoing weekly or monthly treatments. I am not pregnant, nursing, or allergic to any of the components of the treatments. I have informed the doctor if I take blood thinners or have an infection, scleroderma, asthma, keloid scars, bleeding disorder, eczema, psoriasis, cold sores, kidney or liver disease, cancer, allergies, or prior surgeries. I will inform my Healthcare Provider or seek emergency care if I experience any adverse reactions or if I have concerns.

CONSENT FOR TREATMENT 2(Required)

I agree that I am responsible for the payment of all services rendered to me. I agree in the event of non-payment, to pay cost of collection, court, and legal fees. I give consent for non-identifying photos to be used in social media.

CONSENT FOR TREATMENT 3(Required)

Treatment options, their risks, and benefits are reviewed with me. I consent to this and all subsequent treatments. I agree to follow instructions. I release Teresa Camden, MD, her assistants, and the facility from liability associated with this and subsequent procedures. I have read this form and asked questions, which were completely answered.

CONSENT FOR TREATMENT 4(Required)

I consent to FDA off label use of the products and devices used in my treatment.

ACCEPTANCE:

I acknowledge that I have read and fully understand the above consent to have all procedures and treatments performed

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