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Edmund Fisher MD and Noam Rosines MD  for Lüz Lounge

 

 

 

 

Informed consent for Botox/Xeomin/Dysport treatment for Lüz Lounge

This consent form is designed to provide the information necessary when considering whether or not to undergo botulinum toxin treatment for facial and neck wrinkles with Botox® and Xeomin®. Botox®, Dysport ® and Xeomin ® (Botulinum Toxin) are the only FDA approved treatments we use for the temporary reduction of moderate to severe forehead lines and wrinkles, frown lines and/or crow’s feet.

Injection of botulinum toxin causes weakness of targeted muscles, which can last approximately 3–4 months. Injection of small amounts of Botulinum Toxin relaxes the treated muscles and can reduce facial wrinkles such as frown lines. The solution is injected with a small needle into the targeted muscles. Effects are typically seen in a few days and can take 1–2 weeks to fully develop.

Botox is approved by the Food and Drug Administration for the temporary treatment of moderate to severe dynamic frown lines in adults aged 18–65 years and is used off-label for all other cosmetic treatment areas.

The risks, side effects, and complications in treatment with Botox on facial and neck areas include, but are not limited to the following:

  • Localized burning or stinging pain during injection 
  • Bruising
  • Redness
  • Tenderness
  • Swelling
  • Infection
  • Numbness or dysesthesia
  • Headache
  • Anxiety
  • Vasovagal episode with loss of consciousness
  • Facial asymmetry, alteration, or poor aesthetic results
  • Inadequate reduction of wrinkles or lack of intended effect 
  • Blepharoptosis (droopy eyelid)
  • Eyebrow ptosis (droopy eyebrow)
  • Photophobia (light sensitivity)
  • Impaired eyelid closure and blink reflex
  • Ectropian (lower eyelid exposure)
  • Lagophthalmos (incomplete eyelid closure)
  • Xerophthalmia (dry eyes)
  • Epiphora (tearing)
  • Diplopia (double vision) or vision changes
  • Eye trauma
  • Worsening eye bags
  • Lip ptosis with resultant smile asymmetry
  • Oral incompetence with resultant drooling and/or impaired speaking, eating, or drinking
  • Cheek flaccidity
  • Dysarthria (difficulty articulating)
  • Dysphagia (difficulty swallowing), necessitating nasogastric tube placement in severe cases.
  • Hoarseness
  • Neck weakness
  • Weakening of muscles adjacent to the intended treatment area
  • Autoantibodies against botulinum toxin may be present or develop after treatments rendering treatments ineffective (1–2% of patients treated for cosmetic indication per Allergan).
  • Extremely rare, immediate hypersensitivity reaction with signs of urticaria, edema and a remote possibility of anaphylaxis.
  • Case reports of side effects due to distant spread from the site of injection have been reported with large doses of botulinum toxin, including generalized muscle weakness, ptosis, dysphagia, dysarthria, urinary incontinence, respiratory difficulties, and death due to respiratory compromise.

 

Advisory: It is recommended that you not take aspirin, non-steroidal anti-inflammatory medication, or any blood anti-coagulants before this procedure. These medications may increase the risk of bruising. If you are able to stop these medications, you should do so one (1) week before the procedure. Patients with certain medical conditions may not have this procedure done. These include those with any type of facial paralysis such as Bell’s palsy, Guillain-Barre Syndrome and Myasthenia Gravis. Patients who are pregnant or breastfeeding should not use botulinum toxin.

 

Post-marketing safety data suggest that botulinum toxin effects may, in some cases, be observed beyond the site of local injection. The symptoms may include generalized muscle weakness, double vision, blurred vision, eyelid droop, difficulty swallowing, difficulty speaking, urinary incontinence, and breathing difficulties. These symptoms have been reported hours to weeks after injection. Swallowing and breathing difficulties can be life threatening and there have been reports of death related to spread of toxin effects. The risk of symptoms is probably greatest in children treated for spasticity but symptoms can also occur in adults, particularly in those patients who have underlying conditions that would predispose them to these symptoms. No definite serious adverse event reports of distant spread of toxin effect associated with dermatologic use of cosmetic botulinum toxin at the labeled dose have been reported.

 

By signing this consent: 

  • You agree and understand that the use of aspirin, non-steroidal anti-inflammatory drugs or blood thinning medication within the last 7 days, may increase the risk of post-injection bruising. 
  • You understand the procedure and its side effects. The medical staff have been provided with a thorough and truthful medical history. Additional injections may be necessary, for which we will charge a retouch fee, if optimal effect is not reached in 10 to 14 days. botulinum toxin has only a temporary effect that lasts approximately 3-5 months and you will need to repeat injections 3-4 times a year to continue the effect.
  • You hereby assume all risks, hazards and costs of care or expense associated with or which may arise from such treatment, hereby releasing the personnel and consultants and any sponsoring health care facility or institution and its affiliates and all of their agents and employees from any liability from said treatment except where such risks and hazards are the proximate result of gross negligence. This constitutes the full disclosure and supersedes any previous verbal or written disclosures, advertising or marketing materials prepared by us or other. It is understood that our programs are specialty services and do not have responsibility for your comprehensive medical care.

 

My signature below certifies that I have fully read this consent form and understand the information provided to me regarding the proposed procedure. I have been adequately informed about the procedure including the potential benefits, limitations, and alternative treatments, and I have had all questions and concerns answered to my satisfaction. I understand that results are not guaranteed and I accept the risks, side effects, and possible complications inherent in undergoing Botox treatments.

 

April 21, 2024

 

Pre and Postcare Patient Information:

(Botox/Xeomin/Dysport) Botulinum Toxin Cosmetic Treatments

Before Treatment

  • Avoid aspirin (e.g.,Excedrin), vitamin E, St.John’s wort, and other dietary supplements including ginkgo, evening primrose oil, garlic, feverfew, and ginseng for 2 weeks.
  • Avoid ibuprofen (e.g., Advil, Motrin) and alcohol for 7 days.
  • If possible, come to your appointment with a cleanly washed face.

After Treatment

  • Donot massage the treated areas on the day of treatment.
  • Avoid lying down for 4 hours immediately after treatment.
  • Avoid applying heat to the treated area on the day of treatment.
  • Avoid activities that cause facial flushing on the day of treatment, including consuming alcohol, hot tub or sauna use, exercising, and tanning.
  • Gently apply a cool compress or wrapped ice pack to the treated areas for 15 minutes very few hours as needed to reduce discomfort, swelling, or bruising up to a few days after treatment.
  • If bruising occurs, it typically resolves within 7–10 days.
  • After treatment,oral consumption and/or topical application of Arnica montana may help to reduce bruising and swelling.
  • Botulinum toxin treatment effects take about 1–2 weeks to fully develop and last approximately 2.5–4 months.
  • If 1–2 weeks after treatment you feel that you require a touch-up, please contact the office.

By initialing this form, I certify that I have read and understand both pre and post care instructions and agree to address any concerns/questions I have with Dr. Fisher and/or his medical staff prior to treatment. 

April 21, 2024

I authorize Luz Aesthetics to take photos and/or video for sole purpose of education with marketing materials on our website, social media.  All photos and videos are kept in patients file with a  HIPPA compliant database only accessible to Luz Aesthetics staff. I understand I not be reimbursed for usage. I understand and agree that these materials shall become the property of Luz Aesthetics’s and will not be returned. (If you do not consent to photos for marketing but consent to photos for documentation purposes only, please type "XX")

April 21, 2024

IMPORTANT: I acknowledge the following cancellation policy:

If I do not cancel my appointment within 24 hours of my appointment time, I am subject to a $25 fee for treatments under 30 minutes,  $50 for treatments over 30 minutes, $100 for treatments over 60 minutes or prepaid sessions deducted from my account.

April 21, 2024

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STATE MEDICAL SERVICES CONTRACT  

All Medical treatments are performed by Edmund Fisher M.D. and Noam Rosines MD, for Lüz Lounge

A signed copy of this document is to be emailed/given to the client upon request. Original is to be filed in Client’s medical records. Arbitration Agreement CD0501Y8v2

ARTICLE I: ARBITRATION Article 1.1: Agreement To Arbitrate: It is understood that any dispute as to medical malpractice by Client, including any party that would have standing to assert a claim on behalf of or in connection with services provided to Client, that is as to whether medical services rendered under this contract were unnecessary, unauthorized or lacking informed consent or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by State law, and not by a lawsuit or resort to court process except as State law provides for judicial review of arbitration proceedings. For purposes of this agreement, “Dispute” means any claim or controversy of whatever kind or nature including (without limitation) any claim or controversy regarding the formation, validity, interpretation and/or enforceability of this agreement to arbitrate and any claim or controversy by the Client asserting loss of consortium, wrongful death, emotional distress or punitive damages.  Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.  Article 1.2: Procedure For Initiating Arbitration: Either party to this agreement may initiate Arbitration by submitting a Demand for Arbitration in writing to the other. The Demand shall contain a plain and simple statement of the nature of the Dispute and the remedy demanded. There shall be one Arbitrator who shall be a retired Judge of a court of record. The Arbitrator shall be selected by agreement of the parties on or before 30-calendar days of the date that the Demand for arbitration is deposited for delivery with a common carrier (as determined by a postmark or other equivalent writing imprinted by the common carrier). If the parties have not agreed to a selection of the Arbitrator, than either party may petition the appropriate Superior Court to appoint the Arbitrator and, consistent with CCP § 1281.6, the Superior Court shall appoint the Arbitrator, who shall have the qualifications stated in this paragraph.  Article 1.3: Law Governing Arbitration; Arbitrator’s Award And Enforcement. Without reference to its choice of law rules, the Arbitrator shall apply the substantive law of State. The Arbitrator shall render his or her award in writing and the award shall separately state the Arbitrator’s findings of fact and conclusions of law. The Arbitrator’s award shall be binding on the parties to the arbitration and judgment on the award may be entered by a court of competent jurisdiction in State. Judicial proceedings to confirm, amend, or vacate the arbitration award shall also take place in State. To the extent permitted by law, venue for such proceedings shall be in the county (or the federal judicial district) where the services were rendered. Unless the Arbitrator shall determine otherwise, the Arbitration shall take place in the county where the services were rendered. The Arbitrator shall have the authority to hear any claim and award any remedy that could otherwise be heard or rendered by the Superior Court of State or a federal district court in State. Discovery shall proceed in accordance with State Code of Civil Procedure, §§ 1283.1, 1282.05, and, in addition, any party, may, of right, bring a motion for summary judgment or adjudication in accordance with CCP § 437c. The parties to this agreement agree to arbitrate in one proceeding all claims arising out of the same or a related incident, transaction or occurrence.Article 1.4: Small Claims Court: Notwithstanding the foregoing any party to this agreement may initiate and prosecute in the small claims division of the Superior Court any claim at law demanding an amount equal to or less than the jurisdictional limit of the small claims division. Notwithstanding applicable law, no judgment in an action initiated in the small claims division may be entered for an amount in excess of the jurisdictional limit of the small claims division.  Article 1.5: Severability: If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provisions.  NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY MUTUAL ARBITRATION AND YOU ARE GIVING UP  YOUR RIGHT TO JURY OR COURT TRIAL. 

I have read and agree to the terms/conditions listed in this agreement and understand that I have the right to receive a copy of this arbitration agreement upon request.

 April 21, 2024

 

I understand I’m getting consulted and treated by Dr. Edmund Fisher and Noam Rosines MD Nurse Practitioners and Registered Nurses today

April 21, 2024

 

 

 

 

Please select who will be treated...
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First Patient's Name

First Name*

Middle Name

Last Name*
First Patient's Date of Birth*
First Patient's Information

Social Security Number *

Please list all medical conditions, past and present. Are you currently under the care of a doctor/specialist? Do you take any medications for your condition? (name and dosage)

Are you currently on any medications? (prescription, herbal supplements, and/or vitamins?) If "yes" please list all medications, dosage and reason for taking. Leave blank for none.

Do you have a history of any neurological or muscular disorders? Please list otherwise leave blank.
Do you have any allergies?*
No
Yes

If yes was selected for allergies, please list here.
Have you ever had an adverse/allergic reaction to Botox/Xeomin?*
No
Yes

If yes, please list and describe allergic reaction.
Do you have any allergies to anesthetic? (topical or injectable)*
No
Yes
Pregnant or breastfeeding?*
No, I am not Pregnant
Yes I am Pregnant or Breastfeeding
Have you had Botox/Xeomin/Dysport in the past?*
No
Yes

If you have had Botox/Xeomin/Dysport in the past, please indicate how long ago, what product was used (if applicable) and how many units were used (if applicable)
Allergy to cows milk protein? (Not lactose intolerant)*
No
Yes
I am NOT taking any of the following aminoglycoside antibiotics or calcium channel blockers: gentamicin, amikacin, tobramycin, neomycin, streptomycin, Nifedipine, Procardia, Amlodipine Norvasc, Diltiazem, Cardizem, Verapamil. These medications can potentiate the effects of neuromodulators.*
No, I am not taking any of the above.
Yes, I am taking one of the following
I'm interested in learning more about.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Coolsculpting (fat reduction and body contouring)
Cortisone injections for cystic acne
Developing a customized 3, 6 or 12 month skin care plan
Eyelash extensions
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Laser Hair Removal
Micro-blading eyebrows
Microdermabrasion
Microneedling
Platelet Rich Plasma (PRP) facial and/or Hair restoration
Red Light therapy/Infrared
Reducing melasma (pregnancy mask)
Reducing rosacea
Removing broken capillaries
Removing brown spots/sun damage
Skin tightening
Tattoo removal
Teeth whitening
Ultherapy or High Intensity Focused Ultrasound (HIFU)
Vitamin B-12 injections
First Patient's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Social Security Number *

Please list all medical conditions, past and present. Are you currently under the care of a doctor/specialist? Do you take any medications for your condition? (name and dosage)

Are you currently on any medications? (prescription, herbal supplements, and/or vitamins?) If "yes" please list all medications, dosage and reason for taking. Leave blank for none.

Do you have a history of any neurological or muscular disorders? Please list otherwise leave blank.
Do you have any allergies?*
No
Yes

If yes was selected for allergies, please list here.
Have you ever had an adverse/allergic reaction to Botox/Xeomin?*
No
Yes

If yes, please list and describe allergic reaction.
Do you have any allergies to anesthetic? (topical or injectable)*
No
Yes
Pregnant or breastfeeding?*
No, I am not Pregnant
Yes I am Pregnant or Breastfeeding
Have you had Botox/Xeomin/Dysport in the past?*
No
Yes

If you have had Botox/Xeomin/Dysport in the past, please indicate how long ago, what product was used (if applicable) and how many units were used (if applicable)
Allergy to cows milk protein? (Not lactose intolerant)*
No
Yes
I am NOT taking any of the following aminoglycoside antibiotics or calcium channel blockers: gentamicin, amikacin, tobramycin, neomycin, streptomycin, Nifedipine, Procardia, Amlodipine Norvasc, Diltiazem, Cardizem, Verapamil. These medications can potentiate the effects of neuromodulators.*
No, I am not taking any of the above.
Yes, I am taking one of the following
I'm interested in learning more about.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Coolsculpting (fat reduction and body contouring)
Cortisone injections for cystic acne
Developing a customized 3, 6 or 12 month skin care plan
Eyelash extensions
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Laser Hair Removal
Micro-blading eyebrows
Microdermabrasion
Microneedling
Platelet Rich Plasma (PRP) facial and/or Hair restoration
Red Light therapy/Infrared
Reducing melasma (pregnancy mask)
Reducing rosacea
Removing broken capillaries
Removing brown spots/sun damage
Skin tightening
Tattoo removal
Teeth whitening
Ultherapy or High Intensity Focused Ultrasound (HIFU)
Vitamin B-12 injections
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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