Client Intake
Please fill out the following form in order to participate in our services.
Please check any conditions that apply to you:
Authorization to Release Photographs
I authorize Revived Body to release any and all photographs taken for the following uses: social media, office photo gallery, submission for educational purposes.
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I understand that I will not be identified by name in these photographs. Every attempt will be made to cover-up or remove identifiable features (such as tattoo); however in some circumstances, the photograph may portray features which make my identity recognizable.
** your decision to release the photographs will not affect your treatment **
Client Consent
BOTOX / DYSPORT / JEUVEAU / XEOMIN
Proposed Treatment
BOTOX/DYSPORT/JEUVEAU/XEOMIN is Botulinum Toxin Type A (so called as Miracle Poison), a substance has been used for more than a decade to improve spasm of the muscles around the eye, to correct double vision due to muscle imbalance as well as numerous other neurological uses. BOTOX/DYSPORT/JEUVEAU/XEOMIN Cosmetic is now approved by the FDA to improve the appearance of the vertical lines between the brows. A few tiny injections of BOTOX/DYSPORT/JEUVEAU/XEOMIN Cosmetic relax overactive muscles and soften those vertical lines. As such, it may be used to temporarily relax certain facial muscles, thus having a cosmetic effect by smoothing certain facial wrinkles (“Crow’s feet” and other lines of expression).
Anticipated Benefit
The effect of BOTOX/DYSPORT/JEUVEAU/XEOMIN begins in a few days and lasts from 2- 6 months, at which time retreatment is necessary to gain a similar muscle relaxant effect. Occasionally, “touch-up” injections may be required for full effect.
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BOTOX/DYSPORT/JEUVEAU/XEOMIN works best for "dynamic" lines and wrinkles (lines in motion), and is less effective for fine textural changes on the skin surface and for "static lines" (lines present at rest). It is a temporary treatment, meaning it will have to be repeated on a regular basis to remain effective.
Contraindication of Treatment
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Pregnant or lactating women
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Clients with allergies to egg, human albumin.
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Severe infection, inflammation, (including acne), or dermatitis of areas to be injected
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Facial asymmetry such as Bell's Palsy
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Clients with neurological disorders including Lou Gherig's, myasthenia gravis, multiple sclerosis, Parkinson's disease.
Risks, complications and others:
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Allergic reactions, including rash, itching, local swelling, or more severe reactions.
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BOTOX/DYSPORT/JEUVEAU/XEOMIN contains albumin from human blood, to which certain individuals are allergic. If you have had adverse reactions to certain immunizations or are allergic to eggs, you should not use BOTOX/DYSPORT/JEUVEAU/XEOMIN.
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Because BOTOX/DYSPORT/JEUVEAU/XEOMIN contains human albumin, there is a remote chance of transmission of serious viral diseases. This complication has never been identified, but it is possible.
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Bruising may be possible, especially if BOTOX/DYSPORT/JEUVEAU/XEOMIN is used around the eye area. Typically, these discolored areas disappear with time.
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If used around the eye, BOTOX/DYSPORT/JEUVEAU/XEOMIN may cause difficulty in closing eyelids tightly. The result may be corneal exposure with resultant drying, potential ulceration and visual complications. The affected eyelid may droop. Protective patching and/or medication may be required until this complication has passed.
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The safety of BOTOX/DYSPORT/JEUVEAU/XEOMIN in pregnant women or nursing mothers has not been established.
Please read the following statements carefully. By signing below, I hereby:
Agree to cooperate fully with my Nurse Injector’s recommendations while under treatment, realizing that any lack of cooperation can result in a less-than-optimal result.
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Understand that my Nurse Injector can’t promise that everything will be perfect. I understand the reasons for the proposed treatment and potential benefits to me; it has been explained to me what alternatives there are, if any, to this treatment. I have given a complete and truthful medical history, including all medicines, drug use, pregnancy, etc. I certify that I speak, read and write English. All of my questions have been answered before signing this form and I am willing to undergo this elective treatment.
