NEUROTOXIN COSMETIC DENERVATION INJECTION (BOTOX / DYSPORT / JEVEAU) CONSENT

This form is designed to provide you with the information you need to make an informed decision about whether to have (BOTOX / DYSPORT / JEVEAU) (Botulinum Toxin) treatment. If you have any questions or do not understand the potential risks, please do not hesitate to ask us.

How does (BOTOX / DYSPORT / JEVEAU) work? When a small amount of purified (BOTOX / DYSPORT / JEVEAU) protein is injected into a muscle it causes weakness or paralysis of that muscle. This appears in 5-7 days and usually lasts 3-4 months, but can be shorter or longer. These injections have been used for more than a decade in children and adults to improve the problem of facial muscle spasms. BOTOX has also been useful to correct double vision due to muscle imbalance.

 

For your Safety, You must inform your clinician of any recent illness, use of antibiotics, blood thinners, neurological disorders, NSAIDS, or if you have been diagnosed with any of the following conditions:
• Myasthenia Gravis
• Eaton-Lambert Syndrome
• Amyotrophic Lateral Sclerosis
• Allergy or sensitivity to albumin
• Any disorder that might interfere with neuromuscular function
• Bell’s Palsy
• ALS or MS
Important Information and Informed Consent
• I am not pregnant or nursing, nor have any significant neurological diseases to have this treatment.
• I have requested that Beauty Bar Med Spa attempt to improve my facial expression lines with BOTOX/ DYSPORT. I understand that there are NO GUARANTEES as results vary from person to person and that a very small percentage of people produce antibodies that will not allow them to benefit from BOTOX/ DYSPORT treatments.
• I agree that this constitutes full disclosure and that it supersedes any previous verbal and written disclosures. My signature indicates that I am consenting to receive treatment, having read and understood the information presented above and have been given the opportunity to ask any questions that I might have about this procedure. I have been advised of the risks involved in such treatment and alternative treatments, including no treatment at all.
• I consent to be photographed before, during and after treatment. These photographs shall be the property of (Your Business Name These photographs may be shown for scientific reasons, and/or used in patient education (both in and out of the office). I agree to keep (Your Business Name informed of any change of address so that they can notify me of any late findings.

I understand that I release Beauty Bar Med Spa and its associates, including the Medical Director, Nurse Practitioners or Physician Assistants along with any technician or employee of (Your Business Name) employee involved in my treatment from any liability associated with complications from the BOTOX/DYSPORT procedure.
I certify that I have been given the opportunity to ask questions and that I have

Frown lines between the eyebrows are due to contraction of small muscles in this area. Injecting BOTOX/ DYSPORT into this area will paralyze or weaken these muscles causing temporary improvements or disappearance of frown lines. The FDA has approved BOTOX COSMETIC/ DYSPORT to be used to improve the appearance of the vertical lines between the brows. Although not FDA approved, BOTOX/ DYSPORT have also been used successfully for many years to treat many other areas of the face. Similarly, crow's feet and horizontal forehead lines can also be improved by the injection of BOTOX/ DYSPORT into these areas. Lines at present rest may or may not improve. Aging, heredity and sun damage account for other facial wrinkles and may be treated with other non-surgical cosmetic treatments or surgery.

RISKS AND POTENTIAL SIDE EFFECTS OF NEUROTOXIN (Botulinum Toxin Type A) INJECTIONS

What are the risks associated with treatment? Side effects and complications have been minimal. Occasionally, slight swelling, numbness and/or bruising may last several days after the injection. Some may experience a transient headache at injection site. Rarely, an adjacent muscle may be weaken and cause a temporary droop of the eyelids. Other side effects may include respiratory infection, flu syndrome and nausea. A long term safety review of patients using BOTOX which totaled 853 treatment sessions noted only 9 events of side effects which were minimal and transient. In very small numbers of individuals the injection did not work as satisfactorily or for as long as usual.

Every procedure involves a certain amount of risk, and it is important that you understand the risks involved. An individual’s choice to undergo this procedure is based on the comparison of the risk to potential benefit. Although the majority of clients do not experience the following complications, you should discuss each of them with your treating clinician to make sure you understand the risks, potential complications, and consequences of neurotoxin injections.
Bleeding - It is possible, though unusual, to have a bleeding episode from a neurotoxin injection. Bruising in soft tissues may occur. Should you develop post-injection bleeding, it may require emergency treatment or surgery. Do not take any aspirin or anti-inflammatory medications for seven days before neurotoxin injections, as this may contribute to a greater risk of a bleeding problem.
Infection - Infection is extremely rare after a neurotoxin injection. Should an infection occur, additional treatment including antibiotics may be necessary.
Damage to deeper structures - Deeper structures such as nerves, blood vessels, and the eyeball may be damaged during the course of injection. Injury to deeper structures may be temporary or permanent.
Corneal exposure problems - Some clients experience difficulties closing their eyelids after neurotoxin injections and problems may occur in the cornea due to dryness. Should this rare complication occur, additional treatments, protective eye drops, contact lenses, or surgery may be necessary.
Dry eye problems - Individuals who normally have dry eyes may be advised to use special caution in considering neurotoxin injections around the eyelid region.
Migration of Neurotoxin- Neurotoxins may migrate from its original injection site to other areas and produce temporary paralysis of other muscle groups or other unintended effects.
Drooping Eyelid (Ptosis) - Muscles that raise the eyelid may be affected by neurotoxins, should this material migrate from injection areas.
Double-Vision -Double-vision may be produced if the neurotoxin material migrates into the region of muscles that control movements of the eyeball.
Eyelid Ectropion - Abnormal looseness of the lower eyelid can occur following a neurotoxin injection.
Other Eye Disorders - Functional and irritative disorders of eye structures may rarely occur following neurotoxin injections.

Dermal Filler Consent
Treatment with Restylane, Juvederm, Perlane, Bio-Filler or Collagen can smooth out folds and wrinkles, add volume to the lips, and contour facial features that have lost their fullness due to aging, sun exposure, illness, etc. Facial rejuvenation can be carried out with minimal complications. These dermal fillers are injected into the skin with a very fine needle. The products produce a natural volume under the wrinkle, which is lifted up and smoothed out. The results can often be seen immediately. Treating wrinkles with these dermal fillers is fast and safe and leaves no scars or other traces on the face.

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 such risks include but are not limited to:

1) Post treatment discomfort, swelling, redness, and bruising, discoloration
2) Post treatment infection associated with any transcutaneous injection
3) Allergic reaction
4) Reactivation of Herpes (cold sores)
5) Lumpiness, visible yellow or white patches in approximately 20% of cases
6) Granuloma formation
7) Localized Necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occurs.

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 & DISEASE
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 any of the above mentioned dermal fillers. I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to Lidocaine.

If receiving Collagen I have read the brochure titled "Zyderm®/Zyplast® or Cosmoplast™/Cosmoderm™Collagen Explained" in its entirety and have discussed the risks and benefits of injectable collagen treatment with my physician and/or his/her representative and have had all my questions answered. I understand the information provided.

PAYMENT
I understand that this procedure is cosmetic and that payment is my responsibility.

RESULTS
I am aware that full correction is important and that follow-up touch ups/treatments will be needed to maintain the full effects. I am aware that the duration of treatment is dependent on many factors including but not limited to: age, sex, tissue condition, my general health and life style conditions, and sun exposure. The correction, depending on these factors may last 3-6 months and in some cases longer. I been instructed in and understand post treatment instructions and have been given a copy of them.

I hereby voluntarily consent to treatment. The procedure (s) 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. I certify that if I have any changes occur in my medical history I will notify the office.

INFORMED CONSENT FOR KYBELLA® (DEOXYCHOLIC ACID) AESTHETIC INJECTABLE TREATMENT

INSTRUCTIONS - This is an informed-consent document that has been prepared to help inform you concerning using deoxycholic acid injection injections with Kybella®. The use of aesthetic injections with Kybella has its risks and alternative treatments.

INTRODUCTION - Kybella® is a cytolytic drug indicated for improvement in the appearance of moderate to severe convexity or fullness associated with submental (neck) fat in adults. The safe and effective use of Kybella® for the treatment of subcutaneous fat outside the submental region (neck) has not been established and is not recommended. Kybella® is injected into the fat under the chin (no more than 50 injections or 10mL under the skin). Kybella® injections will be given at least one month apart. Your healthcare provider will decide how many treatments and injections are needed. Any other cosmetic use is considered “off label.”

ALTERNATIVE TREATMENTS - There are alternative forms to Kybella® that are non-surgical and surgical. The non-surgical alternatives consist of topical neck products, weight loss, and neck homeopathic treatments. The surgical alternatives of Kybella® are a neck lift, neck liposuction, and several others. Risks and potential complications are associated with alternative forms of treatment.

RISKS - There are risks of using Kybella®. Every cosmetic procedure involves a certain amount of risk, and it is important that you understand the risks involved. An individual’s choice to undergo a cosmetic procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience complications, you should discuss each risk with your provider or affiliated medical personnel.

IRRITATIONS - Kybella® injections can cause tingling, swelling, itching, skin tightness, and headache. These side effects typically resolve without treatment and do not commonly result in patients discontinuing treatment.

NERVE INJURY - Although unlikely, Kybella® injections could cause nerve injury in the area of the jaw resulting in an uneven smile or facial muscle weakness. In the clinical trials these all resolved without treatment in an average of six weeks. Tell your provider if you develop signs of marginal mandibular nerve paresis (e.g., asymmetric smile, facial muscle weakness), difficulty swallowing, or if any existing symptom worsens.

SWALLOWING - Although unlikely, Kybella® injections can temporarily cause trouble with swallowing. Tell your provider if you have had a history of troubled swallowing before your treatment. If you experience any problems swallowing after your treatment notify your provider immediately.

SKIN ULCERATION - Although unlikely, Kybella® injections could cause superficial skin erosions.

ALOPECIA - Although unlikely, Kybella® injections could cause small patches of alopecia (hair loss) in the treatment area. The hair on a man’s beard can potentially experience patches of hair loss that may be permanent.

BLEEDING - It is possible to experience a bleeding episode during or after injections. Should postprocedure bleeding occur, it may require emergency treatment to drain accumulated blood (hematoma). Ask your provider before taking any aspirin or anti-inflammatory medications for ten days before your procedure, as this may contribute to a greater risk of bleeding.

BLINDNESS – Although extremely rare, aesthetic injectables can cause permeant blindness by blocking the blood supply to the eye. The highest risk areas are around the glabella (the skin between the eyebrows and above the nose), nasal region, nasolabial fold, and forehead. The most common

symptoms are immediate vision loss and pain. Central nervous system complications related to the blindness can occur.

INFECTION - Kybella® should not be injected if there is a preexisting infection in the treatment area. In the rare event an infection occurred after treatment, additional treatment including antibiotics or an additional procedure may be necessary.

BRUISING AND SWELLING- Kybella® injections commonly cause swelling, bruising, pain, numbness, redness, and areas of hardness in the treatment area. You may have bruising within a week or more of having any injectables, so time your treatments with your schedule accordingly. Although wound healing after an injectable procedure is expected, you will want to keep ice on the treated area until it subsides. You may be asked to take a medication to reduce or prevent bruising such as Arnica Montana. Contact your provider if bruising lasts longer than a week or anytime if you are concerned.

DAMAGE TO DEEPER STRUCTURES - Deeper structures such as nerves, blood vessels, and muscles may be damaged during treatment with aesthetic injectables. The potential for this to occur varies according to where the treatment is being performed. Injury to deeper structures may be temporary or permanent.

UNSATISFACTORY RESULT - There is the possibility of an unsatisfactory result from aesthetic injectables. Aesthetic injectables may result in unacceptable visible deformities, loss of function, wound disruption, skin death, and loss of sensation. The procedure may result in unacceptable visible deformities or asymmetry in the treatment area. You may be disappointed with the results of Kybella®. The effectiveness of Kybella® may eventually subside but is not know when or if ever that will occur at this time. It is possible that Kybella® cannot be removed or corrected once inside your neck or body.

ALLERGIC REACTIONS - In rare cases, local allergies to injectables, lidocaine, or topical preparations have been reported. Systemic reactions, which are more serious, may result. Allergic reactions may require additional treatment. Lidocaine, a pain reliever used in most dentist offices, is an ingredient in many injectables. Tell your provider if you have an allergy to lidocaine or other allergies.

MEDICATION REACTION - Tell your provider if you are on, or were recently on, any medications as they may interfere with the ability of the aesthetic injectables to function. Even use of antibiotics and Aspirin should be brought to your provider’s attention. It is not recommended that you undergo this treatment if you are on blood thinners for any reason including bleeding disorders.

HERPES SIMPLEX VIRUS - Tell your provider if you get cold sores, fever blisters, or have been diagnosed with the herpes simplex virus. For your comfort we will recommend that you call your physician before treatment so you can take preventive medication to avoid an outbreak. Aesthetic injectable fillers do no not cause outbreaks, but can trigger a non-active outbreak.

PREGNANCY - Women should not have aesthetic injectables if they are pregnant or may become pregnant, or are breast feeding. PREVIOUS

SURGERY – Tell your provider about all past or planned surgeries and treatments of the face, neck, or chin as these could affect the effectiveness and safety of Kybella®

ADDITIONAL TREATMENTS MAY BE NECESSARY - In some situations, it may not be possible to achieve optimal results with a single aesthetic injectable treatment. Multiple sessions may be necessary. Should complications occur, additional injectables or other treatments may be necessary. INFORMED

CONSENT FOR KYBELLA® (DEOXYCHOLIC ACID) AESTHETIC INJECTABLE TREATMENT 

Informed consent documents are used to communicate information about the proposed injectable treatment along with disclosure of risks and alternative forms of treatments. The informed consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances. This informed consent should not be considered all inclusive in defining other methods of care and risks encountered. Your provider or affiliated medical personnel may provide you with additional or different information, which is based on all the facts in your particular case and the state of medical knowledge. Standards of medical care are determined on the basis of all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve. Even though risks and complications occur infrequently, the risks cited are the ones that are particularly associated with Kybella®. Other complications and risks can occur but are even more uncommon. The practice of medicine and aesthetic injectables is not an exact science. Although good results are expected, there cannot be any guarantee or warranty expressed or implied on the results that may be obtained.

 

I understand light can be used effectively to destroy targets located in the skin with minimum damage to the surrounding tissues. Light is used to lighten, fade or remove photo-damaged skin in a nonablative manner, a procedure known as photo
rejuvenation. Visible sings of photo damage include wrinkling, enlarged pores, course
skin texture, and pigment alterations.

Photo-therapy, despite its high levels of efficacy and safety, is not free of side effects.

1. Erythema (redness) and edema (swelling) of the treated area can occur but usually subsides within a few hours but can last up to seven days or longer.

2. Irritation, itching, and/or a mild burning sensation or pain similar to sunburn may occur within 48 hours of treatment.

3, Pigmentary changes such as hyper pigmentation and hypo pigmentation of the skin in the treated areas can occasionally occur. Mostly it is transient, lasting up to six months, but in rare cases it can be permanent. Most cases of hypo- or hyper-pigmentation occur in people with darker skin or when the treated area has been exposed to sunlight before or after treatment. Occasionally these pigmentary changes occur despite appropriate
protection from the sun.

4. Scarring, which can be hypertrophic or even keloid, can occur.

5. Other known complications of this procedure include blisters, reddening, pinpoint pitted scars, bruising, superficial crusting, burns, pain, and infections.

These side effects are usually temporary, lasting from five to ten days but can be permanent as well.

Keep in mind:

The skin at or near the treatment site may become fragile. If this happens, makeup should
be avoided and the area should not be rubbed, as this might tear the skin. A blue-purple
bruise may appear on the treated area, which might last from five to fifteen days. As the
bruise fades, there may be rust-brown discoloration of this skin, which fades in one to
three months or longer.

Additionally, there is a known and expected loss of hair in the treated areas. In a very small percent of people there is new hair growth in the surrounding areas being treated.

Even though appropriate measures are taken to reduce side effects, they cannot be completely eliminated in every case.

I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume these risks.

There may be other treatment options, such as injections, other types of lasers/light sources or peels. With this in mind, I am choosing this non-invasive treatment for vascular and/or pigment lesions and other indicated skin conditions.

Eye damage can occur from the light and therefore protective eyewear must be worn during all phototherapy sessions.


I have read and understand the Pre and Post-Treatment Instructions.

I agree to follow these instructions carefully. I understand that compliance with recommended pre and post
procedure guidelines are crucial for healing, prevention of scarring, and other side effects and complications such as hyper pigmentation, hypo pigmentation, and other skin textural changes.

I understand that this examination is not meant to replace the necessity for a complete dermatological examination.
Photographs:

I give permission for my photographs to be used to help document my treatment course. Complete confidentiality will be maintained.

No guarantee, warranty, or assurance as been made to me as to the results that may be obtained. I am aware that follow-up treatments may be necessary for desired results.

Most patients require a number of treatments over several months with gradual results occurring over this time. Clinical results will vary per patient. I agree to adhere to all safety precautions and regulations during the treatment.
No refunds will be given for treatments received.

I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment.

The nature and purpose of the treatment have been explained to me. I have read and understand this agreement. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to
refuse treatment.

I release B. Sweet Staff, and specific technicians from liability associated with this procedure.

I certify that I am a competent adult of at least 18
years of age. This Consent Form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and
assigns.

 

REJUVAPEN

MORPHUS8

SECREC

skin needling system allows for controlled induction of the skin’s self-repair mechanism by creating micro injuries in the skin to trigger new collagen synthesis, while not posing the risk of permanent scarring. The result is smoother, firmer and younger looking skin. Skin needling treatments are performed in a safe and precise manner with the sterile needlehead and are normally completed within 30-60 minutes, depending on the selected area.

Side Effects

After the procedure, the skin may be red and flushed in appearance, similar to moderate sunburn. In the treatment area, skin tightness and mild sensitivity may also be experienced. These side effects will diminish within a few hours following treatment and over the next 24 hours. After 3 days, there will be little evidence that the procedure has taken place.

Contraindications

Contraindications and precautions include: keloid or raised scarring; history of eczema, psoriasis, actinic (solar) keratosis, herpes simplex infections, diabetes, and other chronic conditions; presence of raised moles, warts or any raised lesions in the target area. Absolute contraindications include: scleroderma, collagen vascular diseases or cardiac abnormalities; rosacea or blood clotting problems; active bacterial or fungal infections; immuno-suppression; scars less than 6 months old; and facial fillers used in the past 2 - 4 weeks. Treatment is not recommended for patients who are pregnant or nursing.

Patient Consent

I understand that results will vary between individuals. I understand that although I may see a change after my first treatment, I may require a series of sessions to obtain my desired outcome. The concept of microneedlig is “micro-wounds” are created. This triggers your body's wound healing processes to heal your micro wounds immediately. However, the most dramatic results will not be visible until four to six weeks after treatment

The procedure and side effects have been explained to me, including alternative methods. I understand the advantages and disadvantages of this procedure.

I am advised: though good results are expected, the possibility and nature of complications cannot be accurately advised; therefore, there can be no guarantee as expressed or implied either to the success or other result of the treatment. I am aware that the treatment is not permanent and natural degradation will occur over time.

I agree that I have read (or that it has been read to me) and understand this consent form, and that I understand the infor-mation contained in it.

I have had the opportunity to ask any questions about the treatment, including risks or alternatives, and I acknowledge that all my questions about the procedure have been answered to my satisfaction.

 

 

 

My physician/practitioner has recommended bioidentical hormone
therapy delivered by a pellet inserted under my skin for treatment of
symptoms I am experiencing related to low hormone levels.
The following information has been explained to me prior to receiving
the recommended therapy.
OVERVIEW
Bioidentical hormones are hormones that are biologically identical
to that made in my own body. The levels of active estradiol and/or
testosterone made by my body have decreased, and therapy using
these hormones may have the same or similar effect(s) on my body
as my own naturally produced hormones. The pellets are a delivery
mechanism for estradiol and/or testosterone, and bioidentical hormone
replacement therapy using pellets has been used since the 1930’s.
There are other formulations of estradiol and testosterone replacement
available, and different methods can be used to deliver the therapy.
There are no commercially available forms of testosterone, however,
that are formulated specifically for use in women. The risks associated
with pellet therapy are generally similar to other forms of replacement
therapy using bioidentical hormones.

 

RISKS/COMPLICATIONS OF TESTOSTERONE
Risks associated with pellet insertion may include: bleeding from
incision site, bruising, fever, infection, pain, swelling, pellet extrusion
which may occur several weeks or months after insertion, reaction
to local anesthetic and/or preservatives, allergy to adhesives from
bandage(s), steri strips or other adhesive agents.
Some individuals may experience one or more of the following
complications with testosterone: acne, abnormal bleeding or a change
in menstrual cycle (if patient has a uterus), anxiety, breast or nipple
tenderness or swelling, insomnia, depression, mood swings, fluid
and electrolyte disturbances, headaches, increase in body hair, fluid
retention or swelling, mood swings or irritability, rash, redness, itching,
lack of effect (typically from lack of absorption), transient increase in
cholesterol, nausea, retention of sodium, chloride and/or potassium,
weight gain or weight loss, thinning hair or female pattern baldness,
hypersexuality (overactive libido) or decreased libido, overproduction
of estrogen (called aromatization) or an increase in red blood cell
formation or blood count (erythrocytosis). The latter can be diagnosed
with a blood test called a complete blood count (CBC). This test should
be done at least annually. Erythrocytosis can be reversed simply by
donating blood periodically, but further workup or referral may be
required if a more worrisome condition is suspected.
If you are planning to start or expand your family soon, please talk
to your provider about other options.

 

RISKS/COMPLICATIONS OF ESTRADIOL (ONLY
APPLICABLE IF RECEIVING ESTRADIOL IN THE PELLETS)
The side-effects of estradiol are similar to those listed above for
testosterone. Additionally, there is some risk, even when using

bioidentical hormones, that estrogens may cause existing cases of some
breast cancers to grow more rapidly. This risk may also apply to some
undiagnosed forms of breast cancer.
Using estrogen-alone (without progesterone) may increase the chance
of getting cancer of the uterus. Endometrial sampling (biopsy) or
surgery may be required if abnormal bleeding occurs.

 

RISKS/COMPLICATIONS OF ANASTROZOLE
(ONLY APPLICABLE IF RECEIVING ANASTROZOLE
IN THE PELLETS)
Anastrozole is a type of medication called an aromatase inhibitor.
Aromatase inhibitors limit or prevent the conversion of testosterone into
estrogen. Aromatase inhibitors can be used for a variety of conditions
but are most commonly used in patients with a history of estrogen
receptor positive breast cancer.
Anastrozole should not be used in pregnant women and should be
used with caution in women with pre-existing ischemic heart disease.
Anastrozole in pellets should not be given to premenopausal women nor
to women taking oral aromatase inhibitors (anastrozole or letrozole) or
selective estrogen receptor modulators (tamoxifen or raloxifene).
The amount of anastrozole used in pellets is very low. The most common
side-effects for women taking anastrozole are hot flashes, joint pain, and
muscle pain. Because of the low dose in the pellet, these effects are not
usually seen with this type of therapy, however.

 

CONSENT FOR TREATMENT:
I agree to immediately report any adverse reactions or problems that
may be related to my therapy to my physician or health care provider’s
office, so that it may be reported to the manufacturer. Potential
complications have been explained to me, and I acknowledge that I have
received and understand this information, including the possible risks
and potential complications and the potential benefits.
I also acknowledge that the nature of bioidentical therapy and other
treatments have been explained to me, and I have had all my questions
answered. I understand that follow-up blood testing will be necessary
four (4) weeks after my initial pellet insertion and then at least one time
annually thereafter. I also understand that although most patients will
receive the correct dosage with the first insertion, some may require
dose changes.
I understand that my blood tests may reveal that my levels are not
optimal which would mean I may need a higher or lower dose in the
future. Furthermore, I have not been promised or guaranteed any
specific benefits from the insertion of testosterone pellets.
I accept these risks and benefits, and I consent to the insertion of
testosterone pellets under my skin performed by my provider. This
consent is ongoing for this and all future insertions in this facility until I
am no longer a patient here, but I do understand that I can revoke my
consent at any time. I have been informed that I may experience any of
the complications to this procedure as described above.
I have read or have had this form read to me.

 

PELLET ACTIVE INGREDIENTS COULD INCLUDE:

pellets that contain testosterone only.
pellets that contain estradiol and testosterone.
pellets that contain testosterone and anastrozole.