Payment Information and Informed Consent for Treatment

Consent for Treatment

  • I am not pregnant, trying to become pregnant, or breastfeeding.
  • I have no known allergies to botulinum neurotoxin or Xeomin®.
  • I have no known allergies to hyaluronic acid filler or Belotero®.
  • As it relates to the specific area of treatment I am requesting, I have not received injectables in that area within the past 3 months.
  • I have not taken an antiplatelet medication (i.e., Aspirin, Plavix) in the past 7 days.
  • I am not currently taking an anticoagulant medication (i.e., Warfarin/Coumadin, Eliquis, Xarleto).
  • I have never been diagnosed with or undergone treatment for a neurological disorder (i.e., Lambert-Eaton, myasthenia gravis, amyotrophic lateral sclerosis (ALS)).

Xeomin® Treatment

Xeomin® is a botulinum neurotoxin used to relax facial muscles that may contribute to the formation of wrinkles or pain. Treatment temporarily causes a disruption in the nerve signal sent to the muscle, preventing treated areas from contracting. This, in turn, causes the desired treatment effect—smoothing of lines or wrinkles. In a largely painless procedure that lasts around 15 minutes, the highly purified product is injected via a very thin needle into the target muscle group(s). Xeomin® treatment should not be received if you are pregnant, trying to become pregnant or breastfeeding. Results typically last between 3-4 months, but with repeated treatments that duration may increase. Depending on your treatment goals, Xeomin® may work together with Belotero® to provide optimal cosmetic results. Note that Xeomin® may take up to 7 days to achieve desired results. 

Risks and complications that may be associated with Xeomin® treatment include, but are not limited to:


  • Localized pain, infection, inflammation, tenderness, swelling, erythema, and / or bleeding / bruising associated with the injection.
  • The most common side effects observed in clinical trials include the following: headache; eyelid drooping, upper respiratory tract infection, and increased white blood cell count in your blood. Unforeseen risks and risks that are not included on this list: allergic reactions (such as itching, rash, red itchy welts, wheezing, asthma symptoms, or dizziness or feeling faint), heart problems (such as irregular heartbeat and heart attack), and eye problems (including dry eye, reduced blinking, and corneal problems). Tell your healthcare provider or seek emergency medical help right away if you experience a serious side effect.

Belotero® Treatment

Belotero® is a hyaluronic acid dermal filler intended to smooth wrinkles and folds and/or add volume and shape to enhance your natural features. Dermal fillers are injected under the skin with a very thin needle. The treatment provides lift and smooths the tissue, and typically lasts 6-12 months. We have chosen Belotero® since it provides a subtle and natural cosmetic result. During the treatment it is normal to experience some pain or pressure, but Belotero® is manufactured with a Lidocaine numbing agent to help minimize discomfort. Due to the expected bruising and/or swelling associated with dermal fillers, it is not recommended to undergo treatment within 2 weeks of an important occasion to allow time for an optimal result.

Risks and complications that may be associated with hyaluronic acid filler injection include but are not limited to:


  • Bruising, bleeding, redness, swelling, itching and pain associated with the procedure. These symptoms are usually mild and last less than a week but can last longer. Patients who are using medications that can prolong bleeding, such as aspirin, warfarin, or certain vitamins and supplements, should disclose these to their Provider as these may increase bruising or bleeding at the injection site.
  • Small lumps may form under my skin due to the hyaluronic acid filler material collecting in one area. I also understand that I may be able to feel the hyaluronic acid filler material around the injection site. Any foreign material injected into the body may create the possibility of swelling or other local reactions to a filler material in an immune mediated response to wall off the foreign substance.
  • Hyaluronic acid filler, as with any filler material, may move from the place where it was injected.
  • As with all transcutaneous procedures, I understand that injection of any filler material carries the risk of infection that may present shortly after the procedure or months later.
  • Hyaluronic acid filler should not be used in patients with severe allergies, a history of anaphylaxis, or history or presence of multiple severe allergies or hypersensitivity to any of its ingredients.
  • Hyaluronic acid filler can be accidentally injected into a blood vessel, which may block the blood vessel and cause permanent tissue damage or tissue death, or potentially even a heart attack, stroke, or blindness.
  • I understand that the safety of Hyaluronic acid filler with concomitant dermal therapies such as epilation, UV irradiation, or laser, mechanical or chemical peeling procedures has not been evaluated in controlled clinical trials. The application of laser or other energy-based treatments within weeks of Hyaluronic acid filler treatment is not recommended as such treatments may alter the characteristics of the filler. If laser treatment, chemical peeling, or any other procedure based on active dermal response is considered after filler treatment, there is a risk of eliciting an inflammatory reaction at the site. This also applies if filler is administered before the skin has healed completely after such a procedure.

Please check the box below to indicate your acceptance.

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