Consents
CUSTOM FACIALS
Our facial treatments involve a variety of procedures that may require special attention and consent prior to service. Please review the statements below prior to your facial treatment. You understand and agree to the following:
If dermaplaning is administered during a facial, it is designed to remove excess hair and dead skin cells from the top layer of skin. Sensitivity, minimal redness, temporary “stinging” when applying topical products, and minor cuts may occur as a result of the service.
You will inform the aesthetician if I am pregnant or nursing during the time of a service.
You will inform the aesthetician if you are currently on Accutane (Isotretinoin), or have been on in the past 6 months, at the time of facial waxing, chemical peel, or facial service.
If a chemical peel is administered during a facial treatment, it is designed to dissolve the top layer of dead skin. Sensitivity, minimal redness, temporary “stinging” when applying topical products, and possible “burns” may occur as a result of the service.
If the O2 Derm Oxygen Dome is placed during a treatment, slight dizziness may occur, and I will verbalize to aesthetician to remove dome or turn down oxygen flow if this occurs.
You will inform the aesthetician if I have a sensitivity to LED light.
DIAMONDGLOW™
DiamondGlow™ is a next-level skin resurfacing technology that simultaneously exfoliates, extracts, and infuses skin with targeted serums to address specific skin quality concerns. By giving consent to a DiamondGlow™ treatment you acknowledge:
You may experience a scratchy, stinging sensation during the treatment. This sensation will subside during the post-treatment protocol shortly after the treatment is finished.
If you fail to use sunscreen, you are more susceptible to sunburn and hyperpigmentation.
You have not been on medication for acne therapy during the past 6 months.
You have not been using retinoids or any other exfoliating products for the past 3 days and will discontinue the use of retinoids for 1 to 3 days after the procedure.
Facial telangiectasia (small blood vessels) is sometimes more apparent immediately after the treatment when the skin is thin and will diminish after my skin has recovered from the treatment.
You will remove my contact lenses prior to the procedure (if applicable).
You have informed the skin care specialist that you am prone to cold sores and are currently not experiencing an outbreak. Any area around the mouth or face prone to cold sores will be avoided during the treatment.
The skincare specialist performing the treatment uses tools that are either disinfected or disposable.
Your skin may experience temporary tightness, mild erythema (redness), or slight swelling, which should dissipate in a few hours following the treatment.
If you are pregnant, lactating, have rosacea, salicylate/aspirin sensitivity, or an outbreak of any skin condition, you should consult with your physician prior to receiving the DiamondGlow™ treatment.
FILLER
As our patient, you have requested the administration of Restylane®/Juvéderm®/Sculptra®/Radiesse®; resorbable implant products approved by the FDA for the correction of moderate to severe facial wrinkles and folds.
Risks
Injection-related reactions occur and include bruising, swelling, pain, itching, discoloration, and tenderness at the treatment site. Increased bruising and bleeding are common in patients taking medications that reduce blood clotting such as aspirin, ibuprofen, Naprosyn, Motrin, Advil, Aleve, Fish Oil or Omega 3 supplements.
We recommend stopping such medications 5-7 days prior to the procedure. Adverse reactions generally disappear within a few days but may last several weeks or longer.
As with all injections, this procedure carries the risk of infection. The syringe is sterile and standard precautions associated with injectable materials are taken. Rarely, small lumps form under the skin due to the product collecting in one area. Product can sometimes be felt in the skin, which is normal. Please call the clinic if you have a visible lump.
Some patients experience swelling or tenderness at the injection site and, on rare occasions, pustules form. These reactions can last 4 weeks and may need to be treated with oral corticosteroids, antibiotics, or other therapy.
Dermal fillers can be inadvertently injected into blood vessels causing local tissue damage or, in very rare circumstances, heart attack or stroke. Dermal fillers should not be used in patients who have experienced hypersensitivities, severe allergies, or in areas of active inflammation or infections (e.g., cysts, pimples, rashes, or hives).
Benefits and Alternatives
Dermal filler has been shown to be safe and effective when compared to collagen implants and related products. Results can last 6-24 months, depending on the type of filler used. This is a voluntary cosmetic procedure. No treatment is necessary or required.
HYLENEX INJECTIONS
I understand that no guarantee can be made as to the result of treatment & that hyaluronidase use for filler corrections is an off-label non-approved use. Dr. Ann Aesthetics and medical staff cannot be responsible for any results of treatment from any other physician or service provider. I will not hold Dr. Ann Aesthetics or medical staff legally or financially responsible for anything resulting from the treatment, current or prior, that I deem unsatisfactory. I acknowledge and accept that the provider treating me has informed me fully that results are not guaranteed and vary from person to person. I acknowledge that Dr. Ann Aesthetics and associated Medical Providers have explained the procedure in detail during a consultation and has made me fully aware of all the possible outcomes and/or side effects (bruising, swelling, pain, possibility of lumpiness or irregularity in the contour of the treated area and/or textural changes to the skin that may last for weeks).
IV THERAPY
You have informed the provider of all current medications and supplements you are taking, as well as any known allergies to drugs or other substances, or of any past reactions to anesthetics. You understand that you have the right to be informed of the procedure, any alternative options, and the risks and benefits of IV therapy.
This procedure involves inserting a needle into the vein and injecting a prescribed solution. Alternatives to IV therapy include, but are not limited to, oral supplementation.
The potential risks of IV therapy include, but are not limited to:
Occasionally: Discomfort, bruising and pain at the injection site.
Rarely: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.
Extremely rarely: Severe allergic reaction, anaphylaxis, infection, cardiac arrest, and death.
Benefits of IV therapy include:
Injectables are not affected by stomach, or intestinal absorption disturbances.
Total amount of infusion is available to the tissues.
Nutrients are forced into cells by means of a high concentration gradient.
Higher doses of nutrients can be given than is possible by oral consumption
You am aware that other unforeseeable complications may occur. You do not expect the provider to anticipate and/or explain all risks and possible complications. You rely on the provider to exercise judgement during the course of treatment with regards to the procedure.
KYBELLA
Kybella (deoxycholic acid) is an FDA approved injection indicated for improvement in the appearance of moderate to severe convexity or fullness associated with submental fat and is injected into the fat under the chin.
Procedure
The results of Kybella are not immediate. You will receive a series of injections in the submental area. At the time of injections and for several days following the injections you will have swelling in the submental area. Kybella will cause fat cells to diminish over the course of the next month following your injections in the treated area. A series of treatments may be necessary to achieve optimal results and these should occur at two-month intervals. You and your provider will discuss the appropriate number of treatment sessions needed.
Risks
Kybella injections commonly cause swelling, bruising, pain, numbness, redness, and temporary firm nodules in the treatment area. Kybella injections can also cause tingling, itching, skin tightness and headache. These side effects typically resolve without treatment and do not commonly result in patients discontinuing treatment.
Other less common potential side effects include:
Nerve Injury in the jaw area is possible, resulting in an uneven smile or facial muscle weakness. In the clinical trials these all resolved without treatment in an average of 6 weeks.
Can temporarily cause trouble with Swallowing.
Superficial Skin Erosions.
Alopecia (small patches of hair loss) in the treatment area.
There is a possibility of an Unsatisfactory Results from injections of Kybella. The procedure may result in unacceptable visible deformities or asymmetry in the treatment area.
Allergic Reactions have been reported in rare cases.
In the rare event an Infection occurred after treatment, additional treatment including antibiotics, or an additional procedure may be necessary.
If you develop signs of marginal mandibular nerve paresis (asymmetric smile, facial muscle weakness), difficulty swallowing, or if any existing symptom worsens, inform your provider.
LASERS
The providers at Dr. Ann Aesthetics have extensive training and experience in the use of medical grade lasers, lights, and radio frequency devices. It is our job to choose the treatment modality that best suits your aesthetics desires, your skin’s needs, and your budget. These are powerful devices with which we cause a controlled injury to improve the appearance, and often the quality and efficiency, of the skin. As with any procedure, there are risks to consider when choosing to have any laser/light/radiofrequency procedure performed.
Risks (include, but not limited to):
Swelling
Burns
Redness, sometimes prolonged (days to weeks)
Scarring, including keloid-type scars
Hyper or hypo pigmentation, which may be permanent.
Eye injury/blindness, which we have never seen, but is possible.
Infection
Reactivation of Herpes (Cold Sores) or Varicella Virus (Shingles)
Cautions
Accutane (Isotretinoin) should not be used within 12 months of any laser, light, or radiofrequency procedure.
Limitations
You understand that my results are limited by the equipment capability, as well as personal skin characteristics, and certain medical conditions. Results are cumulative; therefore, a series of treatments is necessary to achieve maximum benefit.
LATISSE
LATISSE is an FDA-approved prescription treatment for hypotrichosis used to grow eyelashes, making them longer, thicker, and darker. Hypotrichosis is another name for having inadequate or not enough eyelashes. The FDA reviewed clinical study results to verify the identity, potency, purity, and stability of the ingredients, and demonstrated that the product is safe and effective for its intended use if used as prescribed.
If you are considering LATISSE (bimatoprost ophthalmic solution 0.03%), it is important to get all the facts before making any decisions. Please feel free to ask your medical provider about any questions you may have regarding LATISSE.
Risks
LATISSE is not right for everyone. Your doctor may have to evaluate your medical history to determine if you are a good candidate. You should not use LATISSE if you have an active eye condition, including an eye infection, have broken or irritated skin on your eyelid, or are allergic to any of its ingredients. If you are using products for elevated intraocular pressure, you should only use LATISSE after consulting with your doctor.
Side Effects
The most common side effects after using LATISSE solution are an itching sensation in the eyes and/or eye redness. This was reported in approximately 4% of patients. LATISSE solution may cause other less common side effects, which typically occur on the skin close to where LATISSE is applied, or in the eyes. These include skin darkening, eye irritation, dryness of the eyes, and redness of the eyelids, and very rarely darkening of the iris in patients with lighter eye colors.
Limitations
Like every routine, applying LATISSE is about consistency and precision. Results happen gradually over time. Upon discontinuation of LATISSE, your eyelash growth is expected to return to its pre-use level. Your doctor or staff member will provide you with verbal instructions on how to apply LATISSE.
MICRONEEDLING/”SKINTOX”/AQUAGOLD
This procedure stimulates collagen production, boosts hydration, softens fine lines, makes scars a bit more subtle, and gives skin a healthy glowing appearance. This therapeutic blend may contain neurotoxins (Botox or Dysport), hyaluronic acid gel, growth factors, and collagen stimulators, as well as various peptides, amino acids, and vitamins.
This treatment (micro channel mesotherapy) involves blended therapeutic agents delivered into the skin using very small needles. Your provider will customize this cocktail of active ingredients with your skin’s needs and your aesthetic goals in mind. The results can be seen anywhere from day 1-7 post treatment and can last up to 3 months. This treatment can be repeated in a series of 3 treatments, performed at one-month intervals, or can be performed as a stand-alone prior to a big event, vacation, holiday season, or any time the patient desires a more-refreshed appearance.
Risks
Risks of the procedure include temporary redness, bleeding and bruising, mild swelling, itching or rash, reactivation of the cold sore virus or the chicken pox virus (shingles), scarring or keloid formation and skin infection. Apart from bleeding and bruising with the microinjection technique, these risks are unlikely. If you have a known skin-sensitivity to any of the therapeutic ingredients listed, you should make your provider aware prior to the procedure so that ingredient is not included in your customized blend of active ingredients. I understand that I will also need to sign the Dermal Filler and Neurotoxin consent forms, as these two ingredients are commonly included in the therapeutic blend.
MORPHEUS8
Morpheus8 technology utilizes fractional radiofrequency (RF) indicated for facial, neck, chest, back of hands, and small body areas. Treatment induces ablation, thus improving the appearance of rough texture, fine lines, wrinkles, and depressed scars, such as acne scars along with superficial pigments that will be ablated. The treatment also induces skin rejuvenation by heating of the dermis which stimulates collagen generation and replenishment, as well as closure of superficial fine blood capillaries.
The treatment requires anesthesia that involves topical cream, injections, or sedation according to the treatment parameters.
Benefits and Alternatives
There may be alternative procedures or methods of treatment, such as fractional lasers for ablation (CO2) and lasers, IPL or RF based systems for skin rejuvenation. This is a voluntary cosmetic procedure. No treatment is necessary or required.
I understand that the treatment requires a series of sessions (1-5), a few weeks apart (3-6 weeks), according to treatment parameters and individual response. I understand that I must comply with treatment schedule, otherwise results may be compromised.
Side Effects
Possible side effects of the treatment include: local pain, skin redness (erythema), swelling (edema), damage to the natural skin texture (crust, blister, burn), change of skin pigmentation (hyper- or hypo-pigmentation), and scarring. Although these effects are rare and expected to be temporary, redness and swelling may last up to 3 weeks, and are part of a normal reaction to the treatment. Burns and resulting pigmentation change and scarring are rare and may happen in dark skin that is not taken care according to instructions. Tiny scabs appear on the face for a few days as part of a normal healing, however make-up may be applied as soon as 1-3 days after the session to mask them and residual redness. Any adverse reaction should be reported immediately.
NEUROTOXINS
As our patient, you have requested the administration of BOTOX®/Dysport. These are prescription medications that are injected into muscles and used to improve the look of moderate to severe lines.
Procedure
For the purposes of improving the appearance of wrinkles, small doses of BOTOX®/Dysport are
injected into specific facial muscles and immobilizes or weakens them. Treatment begins to work within 24 to 48 hours, peaks at two weeks, and can last up to four months. Subsequent treatments are required to maintain the desired effects. This is a voluntary cosmetic procedure. No treatment is necessary or required.
Risks
Injection-related reactions can occur and include, bruising, swelling, tenderness, and headache. Increased bruising and bleeding are common in patients taking medications that reduce blood clotting such as aspirin, ibuprofen, Naprosyn, Motrin, Advil, and Aleve. We recommend stopping such medications 5-7 days prior to the procedure. Other risks and complications of BOTOX®/Dysport injections include, but are not limited to: allergic reactions, abnormal facial expression, paralysis of a nearby muscles, disorientation, double vision, facial pain, asymmetrical appearance, headache, nausea, flu-like symptoms, impaired swallowing/speech, permanent muscle atrophy, nerve irritability and production of antibodies with unknown general health effects. BOTOX®/Dysport should not be used on pregnant or lactating women, or in people who have myasthenia gravis or any other neurological disorder. There is no guarantee that wrinkles will disappear completely, or that you will not require additional treatments to achieve the desired results. While the effects typically last 3-4 months, the procedure is temporary and additional treatments are required to maintain desired results.
PDO THREADS
You elect to have the PDO (polydiaxonone) Thread Lift procedure and Smoothing procedure uses absorbable surgical sutures placed into the subdermal layer of the skin to initiate collagen production. The procedure can result in increased firmness and elasticity of the skin in the treated area.
Possible Risks and Side Effects include:
Some discomfort may be experienced during treatment.
Sutures are inserted using a small needle, which must heal. A scar at entry point may occur.
With any minimally invasive procedure, bruising of the treated area may occur along with the potential for swelling and is likely. Infection is rare, but with any injection or incision into the skin, the possibility exists.
You may experience some bleeding during the procedure. Hematoma or a small blood clot may occur and may require treatment by drainage. There is a higher risk of bleeding if you have taken any anti-inflammatory medications (Advil, Motrin, Aspirin, Ibuprofen) within the 10 days preceding the procedure.
Deeper structures such as nerves, blood vessels and muscles may be damaged during the procedure. The potential for this to occur varies according to the location on the body the procedure is being performed. Injury to deeper structures may be temporary or permanent.
Allergies to tape, suture material or topical preparations have been reported.
PDO Lift may not correct all your facial laxity or sagging.
Complications may occur as a result of smoking, using a straw, or similar motions. Smoking and similar actions are strongly discouraged. Slight asymmetry, redness, visible sutures, suture breakthrough may require additional treatment or removal of the sutures.
You are not pregnant, trying to get pregnant, or nursing. You do not have or have not had any major illnesses which would prohibit me from receiving dermal fillers. You do not have allergies or high sensitivity to medications, including but not limited to lidocaine.
PHOTOGRAPHY
Photographs are taken for clinical documentation and to monitor progression, however, my identity of the patient is always be protected unless given written consent to distribute for marketing purposes.
PRF
The PRF technique uses the latest generation of smart blood concentrates to generate a complex fibrin matrix rich in platelets, leukocytes, and mesenchymal stem cells, resulting in the release of growth factors and regenerating processes.
The procedure may require a patient to return for numerous visits to achieve the desired results or to determine whether PRF may not be completely effective at treating the condition. The healing process takes time, and the final result will not be readily visible for many months.
On or Off-label use only concerns marketing & promotional material for a product. Physicians are free to use any medical device for any purpose, even a use not approved by the FDA. PRF technique is used to accelerate tissue healing and skin regeneration processes through Blood Concentrate. This proposed use is “Off-label” that is, not specifically approved by the FDA. It is important to understand that the proposed use is not experimental and if suggested by your provider, it is because it is safe and effective.
Possible side effects include:
Discomfort during blood draw where there is a slight pinch to insert the needle for the blood collection, as well as during the procedure if PRF is injected into the site.
Bruising, swelling, and/or infection of the treated area may occur.
Scarring at entry point is extremely rare, but possible when entering the skin. Delayed wound healing and/or scarring may occur.
Contraindications, such as smoking, may have less response to this treatment as toxins in smoke block the response of the Stem Cells.
You understand that my practitioner may discover other conditions, which may necessitate different procedures than stated above. You authorize the practitioner and such associates, to perform such other procedures which are advisable in their professional judgment.
SKINPEN
The SkinPen® Precision system is a microneedling device and accessories intended to be used as a treatment to improve the appearance of facial acne scars in adults aged 22 years or instrument into the body) and precise manner with the use of the sterile needle head.
After the procedure, the skin will be red and flushed in appearance, like a moderate sunburn. You may
also experience skin tightness and mild sensitivity to touch on certain areas. This will diminish significantly within a few hours following the procedure. Within the next 24 hours, the skin will often appear to have returned to normal. After three days, there is rarely evidence that the procedure has taken place.
Please review the following statements prior to your SkinPen® treatment:
You have no known allergy to stainless steel or anesthetics.
You do not have a hemorrhagic (bleeding) disorder or hemostatic (bleeding) dysfunction.
You are not pregnant or nursing.
You are not currently taking drugs with the ingredient isotretinoin (such as Accutane).
You are not have active skin cancer in the treatment area(s).
Although you may see a change after my first procedure, you will likely require a series of sessions to obtain my desired outcome.
Results of microneedling procedures vary among individuals.
The procedure is not permanent and natural degradation may occur over time.