200 SW 8 th St, STE A, Ocala, FL PH: FAX: Dr. Omar Garcia, Medical Director

Transcription

1 200 SW 8 th St, STE A, Ocala, FL PH: FAX: Dr. Omar Garcia, Medical Director

2 BRIEF MEDICAL HISTORY Name Phone Age Height Weight Address City State Zip Current Physician's Name Phone: MEDICATIONS: list all current medications (both prescription or over the counter) I do not take anything. ALLERGIES: list all allergies (foods, medications, latex, airborne, etc.) I do not have any allergies. HOSPITALIZATIONS/OPERATIONS: List dates and reasons for any previous hospitalizations/operations. N/A If female, are you pregnant or lactating? Are you currently on Aminoglycosides or any other antibacterial medication to treat bacterial infections. NO, YES, explain: Please mark the appropriate box. Illness I Currently Have I Have Had in the Past Family Member Has or Had N/A Amyotrophic Lateral Sclerosis (ALS) Autoimmune Disease Eaton Lambert Disorder Eye Disease Hepatitis Numbness Muscle Weakness Myasthenia Gravis Vision Problems I understand the information on this form is essential to determine my medical and cosmetic needs and the provision of treatment. I understand that if any changes occur in my medical history/health, I will report it to the office as soon as possible. I have read and understand the above medical questionnaire. I acknowledge that all answers have been recorded truthfully and will not hold any staff member responsible for any errors or omissions that I have made in the completion of this form. Client Signature: : Employee Initials

3 Consent to Botulinum Toxin A Treatment Botulinum Toxin, a neurotoxin produced by the bacterium Clostridium A, can relax the muscles on areas of the face which cause wrinkles associated with facial expressions. Treatment with Botox can cause our facial expression lines or wrinkles to essentially disappear. Areas most frequently treated are: a) glabellar area of frown lines, located between the eyes; b) crow s feet (lateral areas of the eyes); and c) forehead wrinkles. Botox is diluted to a very controlled solution and, when injected into the muscles with a very thin needle, it is almost painless. Clients may feel a slight burning sensation while the solution is being injected. The procedure takes about 15 to 20 minutes and the results last 3 to 5 months. With repeated treatments, the results may tend to last longer. Risks and complications 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 suck risks include, but are not limited to: 1) post treatment discomfort, swelling, redness, and bruising; 2) post treatment bacterial, viral, and/or fungal infection requiring further treatments; 3) allergic reaction; 4) minor temporary droop of eyelid(s) in approximately 2% of injections, tis usually lasts 2 to 3 weeks; 5) occasional numbness of the forehead lasting up to 2 to 3 weeks; 6) transient headache; and 7) flu-like symptoms may occur. Photographs I authorize the taking of clinical photographs and their use for scientific purposes both in publications and presentations. I understand my identity will be protected. Pregnancy, Allergies, & Neurologic Disease I am not aware that I am pregnant, have any significant neurological disease, or have any allergies to the toxin ingredients or to human albumin. Payment I understand that this procedure is cosmetic, and that payment is my responsibility. Results I am aware that when small amounts of purified Botulinum Toxin (Botox ) are injected into a muscle, it causes weakness or paralysis of the muscle. This appears in 3 to 10 days and usually lasts 3 to 5 months, but can be shorter or longer. In a very small number of individuals, the injection does not work as satisfactorily or for as long as usual. I understand that I will not be able to frown while the injection is effective, but that this will reverse after a period of months, at which time retreatment is appropriate. I understand that I must stay in the erect posture, and that I must not manipulate the area of the injection for the four (4) hour post-injection period. I hereby voluntarily consent to treatment with Botox injected for the condition known as: Facial Dynamic Wrinkles. The procedure has been explained to me. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure. Patient Signature Doctor Signature Employee Initials

4 Consent for Use of Botox Botox is a brand name for botulinum toxin type A, a neurotoxin that blocks muscle contraction by temporarily inactivating the nerves that control them. The effects of Botox become apparent 2 to 5 days after the injection, and generally last 3 to 4 months. The FDA has approved the use of Botox to treat facial dystonias (spasms), strabismus (crossed eyes), and to soften facial rhytids (wrinkles). There may be alternatives to Botox including medicines or surgery. Unwanted side effects of Botox include, but are not limited to: Local bleeding Bruising Under correction (not enough effect) or overcorrection (too much effect) Facial asymmetry (one side looks different than the other) Paralysis of a nearby muscle leading to: droopy eyelid, double vision, inability to close the eye, difficulty whistling, difficulty drinking from a straw Generalized weakness Permanent loss of muscle tone with repeated injection Flu-like syndrome Development of antibodies to Botox Infection Botox contains human-derived albumin and carries a theoretic risk of virus transmission. There have been no reports of disease transmission through Botox. If you are pregnant, nursing, or are allergic to albumin (eggs), you should no receive injections. Patients taking aminoglycoside antibiotics, or those with Eaton-Lambert Syndrome, Lou Gehrig s disease, or Myasthenia Gravis should not have Botox. I understand the above and have had the risks, benefits, and alternatives explained to me. I give my informed consent for Botox injections today. Patient Signature Doctor Signature Employee Initials

5 After Care Instructions for Botox It is common to experience redness or bumps at the injection site and minimal bruising. All of these are temporary and will subside in 24 to 48 hours. It can take 4 to 10 days to see the full results of the Botox. Any touch-ups would be in 2 weeks. You can return to normal activity immediately, but please follow the instructions below for restrictions on certain activities. 1. Avoid exercise for 4 to 6 hours. 2. Avoid alcohol for 4 to 6 hours. 3. Avoid caffeine for 4 to 6 hours. 4. Remain upright for 2 hours post treatment. 5. Smile and use facial expressions for 1 hour post treatment. 6. Avoid aspirin or other blood thinning medications for 24 to 48 hours post treatment. 7. Avoid wearing any hats or headbands that may place pressure over the eyes or across the forehead. 8. Do not rub or massage areas treated for 24 hours. 9. Avoid excessive heat such as saunas or steam rooms for 24 to 48 hours. If you have any questions or concerns, contact our office at (352)

6 Botox Cosmetic Treatment Form Patient Name (Please Print): DOB: of Service (Treatment): Dilution Used Saline # Units/1.0ml # Units/0.1ml 1.0 cc 100 U/1.0ml 10 U/0.1ml 2.0 cc 50 U/1.0ml 5 U/0.1ml 2.5 cc 40 U/1.0ml 4 U/0.1ml 4.0 cc 25 U/1.0ml 2.5 U/0.1ml 5.0 cc 20 U/1.0ml 2 U/.01ml Chief Complaint: Injection Site Chart Medication Information: Lot Number Expiration Place Label Here Total Units (Forehead) Total Units (Glabellar) Total Units (Crows Feet) Total Units (Other Area) TOTAL UNITS = (R) (L) Note: Please mark diagram (above) with number of units at each injection area as a history of the dosage per area. If touch-up treatments are performed please note original chart. This record is helpful for future treatments as it details the dosages per treatment area prior. Remarks: Injector/Clinician Signature Physician Signature

7 Patient Name: Acct#: of Service: Chief Complaint: 200 SW 8th Street, Suite A, Ocala, FL Phone: (352) Fax: (352) Botox Treatment Form Pre Injection Spasm: LIDS: OD OS BROWS: R L FACE: R L NECK R L 0 = None 1 = Increased Blink 2 = Tolerable Flutter 3 = Mildly Incapacitating Spasm 4 = Serverly Incapacitating Spasm Injection No. Lot No./Vial No. Dilution: 1.25U/0.1ml 2.5U/o.1ml 5.00U/0.1ml 10.0U/0.1ml Total Units - Lids/Brow R L Total Units - Crows Feet R L Total Units - Forehead Total Units - Other TOTAL UNITS Diagnosis: TOTAL COST Plan: Physician Signature