Informed Consent for Injectable Treatment

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Patient Information

Patient Name*

Informed Consent for Injectable Treatment

Copeland Medical LLC
Francis Aubrey Copeland MD
Medical Director
15445 West 49th Drive
Golden, CO 80403

Thank you for choosing this independently owned and operated healthcare facility, We hope you have a good experience here with us today.

Possible medical treatment methods for skin rejuvenation include: Botox, Dysport and Xeomin - FDA approved for cosmetic treatment to counter wrinkles and the effects of aging. They are a purified form of botulinum Toxin A, meaning there is no botulism risk when used properly. They work by blocking the nerves that contract muscles, softening the appearance of aging.

Juvederm, Restylane and Radiesse , FDA approved dermal fillers. The Hyaluronic acid (HA) is human based and safe. It that can provide patients with volume, a smooth, long-lasting fix of facial folds, wrinkles, creases and finer lines.

Disclosure:

Side effects are possible with the above treatments: headaches, swelling, bumps, uneven facial appearance.local numbness, tenderness, rash, inflammation, redness, bruising, pain at the site of injection, mild fever, back pain, drooping eyelids or eyebrows, corneal exposure, corneal ulcerations, impaired vision, respiratory problems such as bronchitis, sinusitis, nausea, dizziness, tightness or skin irritation, muscle weakness in injected and neighboring tissue, and allergic reactions. Infections can occur which in most cases are easily treatable but in rare cases a permanent scarring in the area of injection can occur.

There is also the possibility that other side effects or complications, not presently known, recognized, described or understood may develop now or in the future. Other complications can occasionally be seen include but are not limited to failure to improve quality of life, initial unsightly appearance, interruption of daily life, work routine, home/ family life or social life The results are temporary; and cannot improve sagging skin or wrinkles due to sun-damage or replace the need for a facelift and/or C02 fractional treatment.

Patients should avoid using aspirin, nonsteroidal anti-inflammatory medication such as ibuprofen, St. John’s Wort or high doses Of vitamin E supplement one week prior and after treatment.

Delegation

Aubrey Copeland MD is licensed to practice medicine in the State of Colorado. The delegatee is providing the service pursuant to the delegated authority of the physician and the delegating physician is available personally to consult with the patient or provide appropriate evaluation, treatment or referrals in relation to the delegated medical services.

Acknowledgement

  1. I understand the potential benefits Of the proposed procedure. and alternative treatment options.
  2. I understand there are no guarantees from the treatments provided, that in the practice of medicine there are some risks to treatment.
  3. I understand more than one treatment may be needed to achieve a satisfactory result.
  4. I will disclose a full and accurate personal medical history.
  5. I have read the above disclosure, and by signing below I give consent to proceed with the medical service.
  6. My questions regarding the procedure have been answered satisfactorily by the injectable specialist and have the option to have my consultation performed by the Medical Director, Aubrey Copeland, MD.
  7. I understand the procedure and accept the possible complications.
  8. I hereby release the injectable specialist clinic, and Aubrey Copeland MD from all liabilities associated with the above indicated procedure.
  9. I agree to allow the medical services to be performed by a delegate of Aubrey Copeland MD
  10. I understand most insurance companies will not cover this treatment I agree to comply with after-care guidelines which are crucial for skin healing.
  11. I will not expose my skin to the sun for 72 hours.
  12. In the event of any adverse reaction I will call the healthcare facility promptly at the number above
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