Botox Consent Form

This form is not just a formality — it's a record of your decision to consent to a procedure having considered the risk of both positive and negative outcomes and medical risks listed below, and the impact they may have on your well-being.

Please note that the following info has been read, understood and discussed as required with your clinician.

What is being injected?

Botulinum. The product causes muscle relaxation and suppresses sweating for 2–6 months on average (with wide variation between individuals).

What are the side effects and risks?

• Transient headache, swelling, bruising, bleeding, pain, twitching, itching, puffiness and edema around the eyes
• Allergy including anaphylaxis is possible but very rare; Asymmetry (unevenness)
• Temporary drooping of facial features, including eyebrows, cheeks, and mouth
• Dry eyes; Double or blurred vision

Contraindications: Neuromuscular disorder, pregnancy and nursing.

Limitations and Alternatives

BotulinumToxin is best at treating dynamic facial lines. Lines present at rest may or may not improve and can be unpredictable. Follow-up: additional treatment to get desired effect is an option up to 4 weeks after the initial treatment for a charge.

Agreement

• I understand that results vary between individuals and also with each treatment.
• Photos will be taken before and after the procedure for documentation purposes only and will be used on social media only after obtaining patient consent.
• I am aware that botulinum toxin is not permanent; subsequent treatments may be necessary.
• I affirm that I have stated all medical conditions and answered all questions honestly.
• I state that I have read and understand this consent and information contained in it.
• I also have had the opportunity to ask any questions about treatment including risks vs alternatives.

Dermal Fillers Consent Form

This form is not just a formality — it's a record of your decision to consent to a procedure having considered the risk of both positive and negative outcomes and medical risks listed below.

This form states that you have read, understood and discussed as required with Dr. Kumar.

What is being injected?

Hyaluronic acid, RHA, Boletero, Juvederm, Restylane etc. are injected to lines, correct volume loss or alter proportions. They include in their makeup mainly water, hyaluronic acid, lidocaine anaesthetic, and stabilising molecules such as BDDE.

Risks of Injection

Trauma during the procedure is caused by needles and cannulas passing through tissue, and includes bleeding, bruising, haematoma, damage to underlying structures. In rare cases this could require medical intervention.

Infection: Bacterial, viral or fungal infections can occur post procedure. Injections into the lip area could trigger cold sores (Herpes simplex infections).

Reactions: Rarely occur but can include an immediate reaction causing swelling, and very rarely life threatening anaphylaxis.

Unwanted Visual Side Effects: Lumps, swelling, increase in asymmetry can occur and can be temporary or permanent.

Blood Vessel Blockage: In rare instances a blood vessel may become blocked by the filler and can cause necrosis and permanent scarring. Extremely rare cases of stroke and blindness can also occur.

Patient Consent

• I understand that results vary between individuals and I may need a series of treatments for desired outcomes.
• Photos will be taken before and after for documentation only and used on social media only after patient consent.
• I state that I have read and understand this consent and information contained in it.
• I also have had the opportunity to ask any questions about treatment including risks vs alternatives.

Microneedling with or without PDGF/PRP Consent Form

Microneedling is a collagen inducing therapy modality that allows for controlled induction of the skin's self repair mechanisms by creating multiple micro injuries to the skin to stimulate collagen production. This results in smoother, firmer and younger looking skin and is performed by a sterile microneedling pen.

The area is prepped with local lidocaine cream 30 minutes before the procedure after removing all makeup. The procedure takes about 15–30 minutes. Immediately after the procedure the area is treated with PDGF or the patient's own PRP to give back growth factors for collagen stimulation.

Side Effects

After the procedure the treated skin will be red and flushed, comparable to a moderate sunburn. One may also experience skin tightness and mild sensitivity to touch. Redness will start to diminish within a few hours and roughly by 3 days will return back to normal.

Contraindications

• Keloid or hypertrophic scars
• Active acne or Accutane use in the last 3 months
• History of eczema, psoriasis, or other chronic skin conditions
• Herpes infection, warts, or raised moles

Absolute Contraindications

• Use of any blood thinners in the last 7 days
• Scleroderma or collagen vascular diseases
• Blood clotting conditions
• Active infections
• Pregnancy and breastfeeding
• Skin radiation treatments

Patient Consent

• I understand that results vary between individuals and also with each treatment. I may need a series of treatments for desired outcomes.
• Photos will be taken before and after the procedure for documentation purposes only and will be used on social media only after obtaining patient consent.
• I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and there is no guarantee as expressed or implied either as to the success or other result of treatment. I am aware that microneedling is not permanent as natural degradation and aging will happen over time.
• Because this treatment should not be performed under certain medical conditions, I affirm that I have stated all medical conditions and answered all the questions honestly. I agree to keep Dr. Kumar updated on any change in my health prior to my future sessions and understand that there shall be no liability on the provider nor on the part of Dr. Kumar should I fail to do so.
• I state that I have read and I understand this consent and information contained in it.
• I also have had the opportunity to ask any questions about treatment including risks vs alternatives and all questions have been answered to my satisfaction.