NFC HIPPA Form

INSTRUCTIONS: This is an informed-consent document that has been prepared to help inform you about Botulina Toxin A (BTA)-BOTOX®, Dysport, and Xeomin- injections, its risks, as well as alternative treatment(s). It is important that you read this information carefully and completely. Please initial each page, indicating that you have read the page and sign the consent treatment as proposed by a MediFit of Georgia representative . and agreed upon by you.


GENERAL INFORMATION: Clostridia botulina bacteria produce a class of chemical compounds known as “toxins”. The Botulina Toxin A is processed and purified to produce a sterile product suitable for specific therapeutic uses. Once the diluted toxin is injected, it produces a temporary weakness (chemo denervation) of muscle by preventing transmission of nerve impulses to muscle. The duration of muscle weakness lasts approximately three to four months.

BOTOX has been approved to treat certain conditions involving crossed eyes (strabismus), eyelid spasm (blepharospasm), cervical dystonia (spastic muscle disorder with the neck) and motor disorders of the facial nerve as of April 2002, it has been FDA-approved for the cosmetic treatment of wrinkles between the brows caused by specific muscle groups. Other areas of the face and body such as crow’s feet wrinkles and neck bands may be treated in an “off-label” fashion. BOTOX has also been used to treat migraine headaches, colorectal disorders, excessive perspiration disorders of the armpit and hands, and musculoskeletal pain disorders. BTA injections are customized for every patient, depending on his or her particular needs. These can be performed in areas involving the eyelid region, forehead, and neck. BTA cannot stop the process of aging. It can however, temporarily diminish the look of wrinkles caused by muscle groups. BTA injections may be performed as a singular procedure or as an adjunct to a surgical procedure.


ALTERNATIVE TREATMENTS: Alternative forms of management include not treating the skin wrinkles by any means. Improvement of skin wrinkles may be accomplished by other treatments or alternative types of surgery such as a blepharoplasty, face or brow lift when indicated. Other forms of eyelid surgery may be needed should you have intrinsic disorders affecting the function of the eyelid such as drooping eyelids from muscle problems (eyelid ptosis) or looseness between the eyelid and eyeball (ectropion). Minor skin wrinkling may be improved through chemical skin peels, lasers, injection of fillers or fat, or other skin treatments.

INHERENT RISKS OF BTA INJECTIONS: Every procedure involves a certain amount of risk and it is important that you understand these risks and the possible complications associated with them. In addition, every procedure has limitations. An individual’s choice to undergo a surgical procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience these complications, you should discuss each of them with your plastic surgeon to make sure you understand risks, potential complications, limitations, and consequences of BTA injections. Additional information concerning BTA may be obtained from the package-insert sheets supplied by Allergan.


SPECIFIC RISKS OF BOTOX (BOTULINUM TYPE A TOXIN) INJECTIONS:

Incomplete Result: It is possible to not experience a complete result of targeted muscles. Additional injections to reach the desired level of result can be performed until the goal is achieved.

Asymmetry: The human face and eyelid region is normally asymmetrical with respect to structural anatomy and function. There can be a variation from one side to the other in terms of the response to BTA injection.

Drooping Eyelid (Ptosis): Muscles that raise the eyelid may be affected by BTA, should this material migrate downward from other injection areas. Should this problem occur, it is temporary and additional treatments such as eye drops may be necessary.

Pain: Discomfort associated with BTA injections is usually of short duration.

Migration of BTA: BTA may migrate from its original injection site to other areas and produce temporary weakness of other muscle groups or other unintended effects. BTA has been reported to cause swallowing problems in patients treated for spastic muscle disorders of the neck region (cervical dystonia).

Bleeding and Bruising: It is possible, though unusual, to have a bleeding episode from a BTA injection. Bruising in soft tissues may occur. Serious bleeding around the eyeball during deeper BTA injections for crossed eyes (strabismus) has occurred. Should you develop post-injection bleeding, you may require emergency treatment or surgery. Aspirin, anti-inflammatory medications, platelet inhibitors, anticoagulants, Vitamin E, ginkgo biloba, and other “herbs / homeopathic remedies” may contribute to a greater risk of a bleeding problem. Do not take these for ten days before BTA injections. If you are taking these medications, please inform your surgeon prior to proceeding.


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 patients experience difficulties closing their eyelids after BTA 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.


Unsatisfactory Result: There is the possibility of a poor or inadequate response from BTA injection. Additional BTA injections may be necessary. Surgical procedures or treatments may be needed to improve skin wrinkles including those caused by muscle activity. Unsatisfactory results may NOT improve with each additional treatment.

CONSENT FOR BOTULIN TOXINS (BOTOX, DYSPORT, XEOMIN NEUROTOXINS)

  1. I hereby authorize Medfit of Georgia to perform Botulina Toxins Injection. I have received the following information sheet: Botulina Toxins Injection.
  2. I understand what my medical spa professional can and cannot do, and understand there are no warranties or guarantees, implied or specific about my outcome. I have had the opportunity to explain my goals and understand which desired outcomes are realistic and which are not. All of my questions have been answered, and I understand the inherent (specific) risks to the procedures I seek, as well as those additional risks and complications, benefits, and alternatives. Understanding all of this, I elect to proceed.
  3. I consent to be photographed or televised before, during, and after the procedure(s) to be performed, including appropriate portions of my body, for medical, scientific or educational purposes, provided my identity is not revealed by the pictures.
  4. I realize that not having the procedure is an option.
  5. IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:

a. THE ABOVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN

b. THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT

c. THERE ARE RISKS TO THE PROCEDURE OR TREATMENT PROPOSED

I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED ITEMS. I AM SATISFIED WITH THE EXPLANATION.

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THE PATIENT NAME AUTHORIZES MEDFIT OF GEORGIA LLC TO USE AND OR DISCLOSE PROTECTED HEALTH INFORMATION IN ACCORDANCE WITH THE FOLLOWING:

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RIGHT TO REVOKE AUTHORIZATION

You have the right to revoke this AUTHORIZATION, in writing, at any time. However, your written request to revoke this AUTHORIZATION is not effective to the extent that we have provided services or taken action in reliance on your authorization.
You may revoke this AUTHORIZATION by mailing or hand delivering a wrtitten notice to the Privacy Official of Medfit Of Georgia LLC.The written notice must contain the following information:

Your full name and date of birth, a clear statement of your intent to revoke this AUTHORIZATION, the date of your request, and your signature.
The revocation is not effective until it is received by the Privacy Official.
This AUTHORIZATION is requested by Medfit Of Georgia LLC, for its own use/disclosure of Protected Health Information. (Minimum standards apply.)

You have the right to refuse to sign this AUTHORIZATION. If you refuse to sign this AUTHORIZATION, Medfit Of Georgia LLC will not refuse to provide treatment.

You have the right to inspect or copy the PHI to be used/disclosed.

Patient Information

Patient's Name
Date of Birth
Acknowledgement
Clear Signature
Date of Consent (copy)
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