Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: (please circle which number you prefer as your primary number)

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Poppy French
5 years ago
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v2 Last Name: First Name: Middle: Nickname/Preferred Name: Date of Birth: Preferred Service location: (check one below) Social Security # Downtown or Northbrook Race: (circle one below) American

1 v2 Last Name: First Name: Middle: Nickname/Preferred Name: Date of Birth: Preferred Service location: (check one below) Social Security # Downtown or Northbrook Race: (circle one below) American Indian/Alaska Native Ethnicity: (circle one below) Asian Declined Black/African American Hispanic or Latino Declined Not Hispanic or Latino Native Hawaiian/Pacific Islander Other Race Marital Status: (circle one below) White/Caucasian Single Married Widowed Divorced Other Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: (please circle which number you prefer as your primary number) Preferred Pharmacy Name: Address: City: State: Zip: Employer Information: Name: City: State: Zip Code: Position: Status: Full-Time Part-Time Employer Phone: Emergency Contact: Relationship: Name: Phone #: Insurance Information: D.O.B#: Primary Insurance Plan: Policy #: Group # (if applicable): Policy Holder s Information (if different from the Patient): Relationship: Last Name: First Name: Middle: D.O.B.# If your account is turned over to a collection agency, you will be responsible for any costs incurred in collection of said balance, which may include collection agency fees up to 26% of your outstanding balance, a $35 account placement fee, court costs and attorney fees. I hereby authorize The Women s Group of Northwestern to furnish information to my insurance carriers concerning my treatment and illness, and I hereby assign to the doctor all payments for medical services rendered to myself or my dependents. I understand that I am responsible for any amount not covered by my insurance(s). SIGNATURE (Patient and/or guardian, if minor): DATE:

2 PATIENT INFORMATION AND MEDICAL HISTORY Name. Date: Address City State Zip Home Phone Work Phone: Address Date of Birth Age Sex HISTORY Please check if you have had the following: Diabetes Irregular menses Hepatitis Heart problems Herpes Hypertension Photosensitive Disorder Autoimmune illness Are you under the care of a physician? Current/Recent medications If yes explain Keloid scars Yes No Hives Yes No Skin Cancer Yes No Waxing Yes No Electrolysis Cold Sores Yes No Hypersensitivity to skin products Yes No Skin Infections Yes No Tanning within the last 6 wks Yes No Use of acne products/drugs Yes No Laser skin resurfacing Chemical Peels Yes No Photo sensitizing substances Yes No Laser work of any type Yes No Medical Illness. Are you pregnant? Allergies of any kind including drugs Areas of interest for aesthetic treatment Requested Area of Treatment: BOTOX Frown lines (between the eyes) Horizontal forehead lines Crow's Feet Bunny lines (bridge of nose} Droopy Eyebrow Filler Lip Augmentation. Nasolabial folds. Marionette Lines. Vertical Lip Lines Scar fill-in 737 N. Michigan Avenue Suite 600, Chicago, IL Main/ Fax 1535 Lake Cook Road, Suite 503, Northbrook, IL Main/ Fax

3 THE WOMEN S GROUP OF NORTHWESTERN Chicago / Northbrook PATIENT Date: DATE OF BIRTH EMR #: ADDRESS PHONE: The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives of the procedure named above. This material serves as a supplement to the discussion you have with your doctor/healthcare provider. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing the consent form. THE TREATMENT Treatment with dermal fillers (such as Juvederm, products, Voluma, Vollure, XC Ultra & Ultra Plus, Vobella) can smooth out facial folds and wrinkles, add volume to the lips, and contour facial features that have lost their volume and fullness due to aging, sun exposure, illness, etc. Facial rejuvenation can be carried out with minimal complications. These dermal fillers are injected under the skin with a very fine needle. This produces natural appearing volume under wrinkles and folds which are lifted up and smoothed out. The results can often be seen immediately but my expand within 1-4 weeks to final fullness effect. Initial RISKS AND COMPLICATIONS Before undergoing this procedure, understanding the risks is essential. No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalization, and/or extended outpatient therapy to permit adequate treatment. It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure and in this specific instance such risks include but are not limited to: 1) Post treatment discomfort, swelling, redness, bruising, and discoloration; 2) Post treatment infection associated with any transcutaneous (skin) injection; 3) Allergic reaction; 4) Reactivation of herpes (cold sores); 5) Lumpiness, visible yellow or white patches; 6) Granuloma formation; 7) Localized necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occurs. Initial PREGNANCY AND ALLERGIES 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 would prohibit me from receiving dermal fillers. I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to lidocaine. Initial ALTERNATIVE PROCEDURES Alternatives to the procedures and options that I have volunteered for have been fully explained to me. Initial 1

4 THE WOMEN S GROUP OF NORTHWESTERN Chicago / Northbrook PAYMENT I understand that this is an "elective procedure and that payment is my responsibility and is expected at the time of treatment. Initial RIGHT TO DISCONTINUE TREATMENT I understand that I have the right to discontinue treatment at any time. Initial PHOTOGRAPHY MATERIALS I authorize the taking of clinical photographs and videos and their use for scientific and marketing purposes before and after treatments. Initial RESULTS Dermal fillers have been shown to be safe and effective when compared to collagen skin implants and related products to fill in wrinkles, lines and folds in the skin on the face. Their effect can last up to months. Most patients are pleased with the results of dermal fillers use. However, like any esthetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that wrinkles and folds will disappear completely, or that you will not require additional treatment to achieve the results you seek. The dermal filler procedure is temporary and additional treatments will be required periodically, generally within 4-6 months, involving additional injections for the effect to continue. I am aware that follow-up treatments will be needed to maintain the full effects. I am aware the duration of treatment is dependent on many factors including but not limited to: age, sex, tissue conditions, my general health and life style conditions, and sun exposure. The correction, depending on these factors, may last up to 12 months and in some cases shorter and some cases longer. I have been instructed in and understand the post-treatment instructions. Initial I understand this is an elective procedure and I hereby voluntarily consent to treatment with dermal fillers for facial rejuvenation, lip enhancement, establish proper lip and smile lines, and replacing facial volume. The procedure has been fully explained to me. I also understand that any treatment performed is between me and the doctor/healthcare provider who is treating me and I will direct all post-operative questions or concerns to the treating clinician. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure and I understand that no guarantees are implied as to the outcome of the procedure. I also certify that if I have any changes in my medical history I will notify the doctor/healthcare professional who treated me immediately. I also state that I read and write in English. Patient Name (Print) Patient Signature Date I am the treating doctor/healthcare professional. I discussed the above risks, benefits, and alternatives with the patient. The patient had an opportunity to have all questions answered and was offered a copy of this informed consent. The patient has been told to contact my office should they have any questions or concerns after this treatment procedure. Doctor Name (Print) Doctor Signature Date 2

6 INJECTABLE PRE-INSTRUCTIONS AND INFORMATION 1. To decrease the incidence of bruising and bleeding, refrain from all blood-thinning medications and supplements 14 days before an injectable filler treatment. If you need to take something for the relief of minor aches or pains, YOU MAY TAKE TYLENOL (Acetaminophen). Please refer to your medication sheet for a comprehensive list. If you have any questions, please call our office, and speak with your provider. 2. Please avoid any alcohol for 48 hours before your injectable treatment. 3. If you tend to bruise easily, begin taking homeopathic Arnica 2 days before treatment (used to reduce bruising and swelling) or Arnica Montana as directed which is found at Whole Foods and Vitamin Stores. 4. Ice Compress are used throughout the procedure for your comfort and to help minimize swelling and bruising. 737 N. Michigan Avenue Suite 600, Chicago, IL Main/ Fax 1535 Lake Cook Road, Suite 503, Northbrook, IL Main/ Fax

7 Medication/Supplements to Avoid 1-Week Prior to Botox Treatment AND 2 Weeks Prior to an injectable Filler Treatment Advil Celebrex Goody's Persistin Aleve Cheracol Capsules Heparin Phentermine Allegra Chlortrimeton Ibuprofen Phenylbutazone Alka-Seltzer Clinoril lndocin Pontel Alka-Seltzer Plus Congesprin Chewable Indomethacin Propoxyphene Compound 65 Anacin Cope Tablets lanorinal Robaxisal Anaprox Coumadin Lioresal Rufen Anadynos CP-2 Tablets Lortab Ru-Tuss Ansaid Damason-P Lovenox S.A.C. A.P.C. Darvon Compound Magan Saleto Argesic Darvon Compound-65 Magsal Salocal Arthropan Liquid Darvon N with A.S.A. MarnaI Sine Aid Arthritis Pain Formula Darvon w/a.s.a. Maximum Bayer Aspirin Sine-off Sinus Medicine Arthritis Strength Bufferin Pulvules Measurin Sinutab A.S.A. Di-gesic Medomem SK-65 Compound A.S.A. Enseals Disalcid Methcarbamol w/aspirin Stanback Ascriptin Dolobid Micrainin Stendin Ascriptin A/D Dolprin Mobidin St. Joseph's Aspirin for Kids Ascriptin w/codine Dristan Midol St. Joseph's Cold Tablets Ascriptin Extra Strength Durasal Tablets Mobigesic Sulindac Asperbuf Easprin Momentum Muscular Surmontil Aspergum Ecotin Backache Formula Synalgos Aspirin Efficin Motrin Tagamet Atromid Elavil Mysteclin F Talwin Compound Axotal Emagrin Nalfon Tenuate Dospan Axolid Emprazil Naprosyn Tetracycline Bayer Aspirin Empirin with Codeine Neocylate Tolectin Bayer Aspirin Maximum Encaprin Nicobid Tometin Bayer Children's Aspirin Endep Norgesic Triaminicin Bayer Children's Cold Equagesic Tablets Norgesic Forte Triavil Bayer Time-Release Etrafon Nuprin Trigesic B.C. Tablets and Powder Excedrin Oraflex Trilisate Tablets & Liquids Buff-a-Comp Feldene Orudis Tumeric Buff-a-Comp No. 3 Florinal Pabalate-SF Uracel Buffets II Flagyl Pamelor Vanquis Buffinol Flexeril Parnate Verin Buf-Tabs Four-Way Cold Tablets Pepto-Bismol Tablets Vibramycin Butazolidin Gaysal-S Pepto-Bismol Suspension Voltaren Cams Arthritis Pain Reliever Gelprin Percodan Wine/Alcohol Carisoprodol Gemnisin Persantine Zomax Zorprin HERBAL SUPPLEMENTS Billberry (vaccinum myrtilllus) Cayenne (capsicum annuum) Chia Seeds Cumin Dong QuaL (angelica alnensis) Echinacea (Echinacea augusifolia) Feverfew (tanacetum paithenium) Fish Oil (Omega 3) Flax Seed Garlic (allium sativum) Ginger (zingiber officinate) Ginko Biloba Ginseng (panax ginseng/panax quinquefolium) Hawthorne (crataegus laevigata) Kava Kava (piper methysticum) Licorice Root (gylcyrrhiza glabra) Ma Huang (ephedra sinica) Melatonin Red Clover (trifolium pretense) St. John s Wart (hypericum peforatum) Valerian (valerian officinalis) Vitamin E Yohimbe (corynanthe yohimbe) Any questions on Medication/Supplements to avoid, please call your provider. 737 N. Michigan Avenue Suite 600, Chicago, IL Main/ Fax 1535 Lake Cook Road, Suite 503, Northbrook, IL Main/ Fax

Name. Date: Address City State Zip Home Phone Work Phone: Address Date of Birth Age Sex HISTORY Please check if you have had the following:

PATIENT INFORMATION AND MEDICAL HISTORY Name. Date: Address City State Zip Home Phone Work Phone: E-mail Address Date of Birth Age Sex HISTORY Please check if you have had the following: Diabetes Irregular