Patient Release Forms

The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives of the procedure named above. This material serves as a supplement to the discussion you have with your doctor/healthcare provider. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing the consent form.

Botulinum toxin (Botox® and Dysport) is a neurotoxin produced by the bacterium Clostridium A. Botulinum toxin can relax the muscles on areas of the face and neck which cause wrinkles associated with facial expressions or facial pain. Treatment with botulinum toxin can cause your facial expression lines or wrinkles to be less noticeable or essentially disappear. Areas most frequently treated are: a) glabellar area of frown lines, located between the eyes; b) crow’s feet (lateral areas of the eyes); c) forehead wrinkles; d) radial lip lines (smokers lines), e) head and neck muscles. Botox is diluted to a very controlled solution and when injected into the muscles with a very thin needle, it is almost painless. Patients may feel a slight burning sensation while the solution is being injected. The procedure takes about 15-20 minutes and the results can last up to 3 months. With repeated treatments, the results may tend to last longer.

Before undergoing this procedure, understanding the risks is essential. No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalization, and/or extended outpatient therapy to permit adequate treatment. 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, 2. Double vision, 3. A weakened tear duct, 4. Post treatment bacterial, and/or fungal infection requiring further treatment, 5. Allergic reaction, 6. Minor temporary droop of eyelid(s) in approximately 2% of injections, this usually lasts 2-3 weeks, 7. Occasional numbness of the forehead lasting up to 2-3 weeks, 8. Transient headache and 9. Flu-like symptoms may occur.

I am not aware that I am pregnant and I am not trying to get pregnant, I am not lactating (nursing). I do not have any significant neurologic disease including but not limited to myasthenis gravis, multiple sclerosis, lambert-eaton syndrome, amyotrophic lateral sclerosis (ALS), and Parkinson’s. I do not have any allergies to the toxin ingredients, or to human albumin.

Alternatives to the procedures and options that I have volunteered for have been fully explained to me.

I understand that this is an "elective” procedure and that payment is my responsibility and is expected at the time of treatment.

I understand that I have the right to discontinue treatment at any time.

I am aware that when small amounts of purified botulinum toxin are injected into a muscle it causes weakness or paralysis of that muscle. This appears in 2 – 10 days and usually lasts up to 3 months but can be shorter or longer. In a very small number of individuals, the injection does not work as satisfactorily or for as long as usual and there are some individuals who do not respond at all. I understand that I will not be able to use the muscles injected as before while the injection is effective but that this will reverse after a period of months at which time re- treatment is appropriate. I understand that I must stay in the erect posture and that I must not manipulate the area (s) of the injections for the 2 hours post-injection period.

I understand this is an elective procedure and I hereby voluntarily consent to treatment with botulinum toxin injections for facial dynamic wrinkles, TMJ dysfunction, bruxism and types of orofacial pain including headaches and migraines. The procedure has been fully explained to me. I also understand that any treatment performed is between me and the doctor/healthcare provider who is treating me and I will direct all post-operative questions or concerns to the treating clinician. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure and I understand that no guarantees are implied as to the outcome of the procedure. I also certify that if I have any changes in my medical history I will notify the doctor/healthcare professional who treated me immediately. I also state that I read and write in English.

Treatment with dermal fillers (such as Juvederm, Restylane, Radiesse and others) can smooth out facial folds and wrinkles, add volume to the lips, and contour facial features that have lost their volume and fullness due to aging, sun exposure, illness, etc. Facial rejuvenation can be carried out with minimal complications. These dermal fillers are injected under the skin with a very fine needle. This produces natural appearing volume under wrinkles and folds which are lifted up and smoothed out. The results can often be seen immediately.

Before undergoing this procedure, understanding the risks is essential. No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalization, and/or extended outpatient therapy to permit adequate treatment. 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, bruising, and 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; 6) Granuloma formation; 7) Localized necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occurs.

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 dermal fillers. I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to lidocaine.

I understand that this is an "elective” procedure and that payment is my responsibility and is expected at the time of treatment.

I understand that I have the right to discontinue treatment at any time.

Dermal fillers have been shown to be safe and effective when compared to collagen skin implants and related products to fill in wrinkles, lines and folds in the skin on the face. Its effect can last up to 6 months. Most patients are pleased with the results of dermal fillers use. However, like any esthetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that wrinkles and folds will disappear completely, or that you will not require additional treatment to achieve the results you seek. The dermal filler procedure is temporary and additional treatments will be required periodically, generally within 4-6 months, involving additional injections for the effect to continue. I am aware that follow-up treatments will be needed to maintain the full effects. I am aware the duration of treatment is dependent on many factors including but not limited to: age, sex, tissue conditions, my general health and life style conditions, and sun exposure. The correction, depending on these factors, may last up to 6 months and in some cases shorter and some cases longer. I have been instructed in and understand the post-treatment instructions.

I understand this is an elective procedure and I hereby voluntarily consent to treatment with botulinum toxin injections for facial dynamic wrinkles, TMJ dysfunction, bruxism and types of orofacial pain including headaches and migraines. The procedure has been fully explained to me. I also understand that any treatment performed is between me and the doctor/healthcare provider who is treating me and I will direct all post-operative questions or concerns to the treating clinician. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure and I understand that no guarantees are implied as to the outcome of the procedure. I also certify that if I have any changes in my medical history I will notify the doctor/healthcare professional who treated me immediately. I also state that I read and write in English.

I authorize Dr. Roth, MD and/or SkinLab West Ave, and/or their representative(s), to take photographs, slides/videos of me or parts of my body for the following procedure(s) and for medical purposes to be used for my care, medical presentations and/or articles. I hereby grant permission for the use of any of my medical records including illustrations, photographs or other imaging records created in my case, for use in examination, testing, credentialing and/or certifying purposes by The American Board of Plastic Surgery, Inc.

In addition, I authorize the use of these images, without compensation to me, for the following specific purposes:

I understand that:
Such photographs, slides/videos may be published by Dr. Roth, MD and/or SkinLab West Ave in any print, visual or electronic media including, but not limited to, medical journals and textbooks, scientific presentations, teaching courses, and internet web sites, for the purpose of informing the medical profession or the general public about plastic surgery methods. I understand that such uses may also include marketing on behalf of Dr. Roth, MD and/or SkinLab West Ave, for which Dr. Roth, MD may receive direct or indirect remuneration. I will not be identified by name in any of the media described above; However, I also understand that in some circumstances the photographs, slides/videos may display features that identify me.

I have the right to revoke this authorization in writing at any time and, if I decide to do so, I must present my written revocation to Dr. Forrest S. Roth at 2800 Kirby Drive, Ste. B212. A revocation shall not affect any release of information made prior to revocation in reliance upon this authorization. If I fail to specify an expiration date, event, or condition, this authorization will expire with my written revocation.

I may refuse to sign this authorization without such refusal affecting the medical treatment I receive from Dr. Roth, MD and/or SkinLab West Ave.

The information disclosed under the authorization, or some portion thereof, is protected by state law and/or The Federal Health Insurance Portability and Accountability Act of 1996 (HIPPA). Any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal and/or state confidentiality rules.

A copy of this Authorization is valid as the original. I have received a copy of this authorization. I may inspect or copy information to be used or disclosed under this authorization, as provided by federal and/or state law. I release and discharge Dr. Roth, MD and/or SkinLab West Ave from all liability, including liability for negligence, that in any way arises out of any and all rights that I may have had in photographs, slides/videos of me that I have authorized to be used and disclosed in the authorization; and any claim that I may have or may have had relating to such use and disclosure of those photographs, slides/videos of me, including any claim for payment in connection with any distribution or publication of them in any medium.

This authorization is made as a voluntary contribution in the interest of public education and certify that I have read this Authorization and Release carefully and fully understand its terms. If I have questions about the use of disclosure of my photographs, slides/videos, I can contact the practice at 713-559-9300.

Your appointments are very important to all members of our team as West Ave Plastic Surgery. Time allocation for an appointment is reserved especially for you. We do understand that sometimes schedule adjustments are necessary; therefore, we respectfully request at least 24 hours' notice for adjustments to your appointments and for cancellations. All are policies are designed to benefit our guests and to provide the best quality and tradition of excellent service for our established and future clientele.

Please understand that when you forget or cancel your appointment without giving enough notice, we miss the opportunity to fill that appointment time and clients on our waiting list miss the opportunity to receive services they need. We ask that all new and current guests supply a credit card to have on our files. If we do not receive the required notice for adjustments and cancellations, the following fees will be applied to your card or alternatively billed out to you:

No-Shows or Last-Minute Cancellations will result in a $150 fee. *Notification given at least 24 hours prior to your appointment will not be charged*

We do not offer refunds on services rendered. Aesthetic results are quite variable from person to person. and while we do our best to achieve the desired outcome, it cannot always be guaranteed. Clients are responsible for further treatments need to achieve further results. If you have pre-purchased and have not received the service, your payment will be applied to your account as a credit for future use but will not be refunded.

We do not offer refunds on products purchased. Defective products can be exchanged for the same product only and must be done within 30 days of purchase. Gift Cards are non-refundable.

If you put down a deposit with any of our providers and you cancel last minute, or miss your appointment, you forfeit your deposit. To book a new appointment, you must pay a new deposit.

Should you need to cancel an appointment for any reason, you must provide our office with 24 hours' notice; otherwise we will be forced to collect a $150 cancellation fee on your next visit. This policy also applies when you are 15+ minutes late to your appointment. If at any point you cancel two or more appointments within 30 days of each other, you may be discharged from the program. This is the only way to ensure that your results are maximized within the allotted time of your course of therapy.

I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED POLICIES. I AM STATISFIED WITH THE EXPLANATION AND AGREE TO FULLY COMPLY.