Informed Consent

Is For treatment of unwanted fat in patients with a BMI of 35 or less.
I agree to stay hydrated during the treatment.
I agree that I do not have any metal or electronic implants under the skin. Possible risks include poor cosmetic outcome, changes in skin texture or color, scarring, pain.
I understand that 4-6 sessions may be needed for optimal results.

(Used interchangeably for Botulinum Toxin) Improves wrinkles by causing muscles to decrease function or become paralyzed. This decrease in muscle function is temporary and should be repeated in 3 months. Weakness of adjacent muscles may occur because of the spread of the botulism.

Side effects include, but not limited to, those listed below as well as: temporary ptosis; lid changes; corneal exposure, resulting in impaired or double vision (which is usually temporary); reduced blinking (associated with corneal ulcerations).

For facial contouring or diminishing the appearance of wrinkles. Lasts up to 6 months or longer. By signing this consent form, I am confirming that I do not have severe allergies, particularly allergies to bacterial proteins, which precludes treatment.

Hyaluronidase may be used “off label” to smooth out an unfavorable result of Dermal Filler; or to treat an adverse reaction such as vascular occlusion. In the case of vascular occlusion, the risk of tissue necrosis or blindness cannot be completely removed. I consent to treatment, without skin allergy testing, with hyaluronidase if there is a suspected vascular occlusion.

Improves submental fat, “double chin.” Multiple monthly treatments are required. Side effects include, but are not limited to: nerve injury, causing uneven smile or facial muscle weakness (usually self-limited); temporary trouble swallowing (likely due to neck swelling); skin erosions; hair loss; more noticeable platysma bands; visual deformities.

I consent to the use of Kybella “off label” in the treatment of body fat; and PCDC in the treatment of submental (chin) fat and body fat. I understand the risk of tissue cavitation and arterial fat embolism.

Prp can be used for Hair restoration and multiple treatments are required.

Prp & Prf can be used for skin rejuvenation and other treatments. Possible risk includes but not limited to poor cosmetic outcome, brusing and pain.

I consent to regular, monthly chemical peels. Side effects listed below.

Used to soften wrinkles,lift and tighten skin, and stimulate collagen production. Lasts up to 2 years. Risk/side effects, in addition to those listed below, include partial: correction requiring re-treatment; scarring; visible threads; irregularity or dimpling of skin; hematoma; pigment changes to skin; neuropraxia, or damage to deeper structures of the face. Threads may extrude and may have to be trimmed or removed in the future. PDO Thread Lift is contraindicated in patients with cutaneous neurofibromatosis, excoriation disorders, allergy or foreign body sensitivities to plastic biomaterials, or existing implants in the area of treatment.

Laser therapy is not recommended if any of the following conditions exist: pregnancy, nursing, photosensitivity disorder, immunosuppressive disease, diabetes, bleeding disorder, seizure disorder triggered by light, active herpes, active shingles, or any active infection. I will notify my treating clinician if I have any of these conditions. Laser hair removal is not recommended for individuals who have used Accutane within the last six months or who used medications requiring limited exposure to sunlight. It should be understood that laser treatments may need to be repeated several times before complete satisfaction is achieved. No guarantees have been made to me regarding the outcome of the treatment or any improvements in my condition due to the procedure.

Possible Risks:

• Pain, burning, blister formation, and stinging sensation at the site of treatment.
• Infection associated with the treatment site.
• Pigmentary (color) changes at the treatment sites including a decrease in skin color (hypopigmentation or lightening) and/or increase in skin color (hyperpigmentation or darkening).
  Scar formation at the treated site.
• Laser-induced “cold sore like” blistering skin eruptions known as “herpetic” skin eruptions at the treatment site or surrounding tissue.
• Poor cosmetic outcome.
• Recurrence of vessels at the treated sites.

Results may take up to six months to be visible. Subsequent treatments may be necessary at full value to achieve desired results.

Risks include:

• Redness
• Swelling
• Bruising
• Burning
• Scarring
• Numbness
• Weakness

Cryolipolysis, commonly referred to as fat freezing, is a nonsurgical fat reduction procedure that uses cold temperature to reduce fat deposits in certain areas of the body. The procedure is designed to reduce localized fat deposits or bulges that do not respond to diet and exercise.

• The suction pressure may cause sensations of deep pulling, tugging and pinching. You may experience intense stinging, tingling, aching or cramping as the treatment begins. These sensations generally subside as the area becomes numb.
• Bruising, swelling, tenderness and blistering can occur in the treated area and it may appear red for a few hours after the applicator is removed.
• You may start to see changes as early as three weeks after Fat Freezing, and you will experience the most dramatic results after one to three months. Your body will continue naturally to process the injured fat cells from your body for approximately four months after your procedure
• In rare cases, patients have experienced vasovagal symptoms during the treatment, and reported freeze burn, darker skin color, hardness, discrete nodules, or enlargement of the treatment area. Surgical intervention may be required to correct the enlargement. I understand that these and other unknown side effects may also occur

• I acknowledge that my skin might experience temporary irritation, tightness, redness, or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.
  I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.
• I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm.
• I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied.
• I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 2-4 weeks following treatment.
• I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments
• I release Evexia Medspa and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.

The IV intravenous procedure involves inserting a needle into your vein and infusing over a determined period of time, prescribed nutrients (vitamins, minerals, amino acids) or chelation agents. Your virals will be measured prior to and after your infusion.

IV Risks:

• I acknowledge that I am aware of the risks inherent in peripheral vascular catheterization and infusion that include but are not limited to: local irritation, pain, infection, phlebitis (irritation of the vein), venous thrombosis, shortness of breath, allergic reaction, fluid volume overload, medication interactions, and death. Despite these risks (and others) I consent to the procedure. I may withdraw my consent at any time.

Microneedling Is used with radiofrequency for skin rejuvenation. I agree that I do not have any metal or electronic implants under the skin. Possible risks include poor cosmetic outcome, changes in skin texture or color, scarring, pain, blistering. I consent to regular monthly treatments

Microneedling may be used with PRP from my own blood for skin rejuvenation. Multiple treatments are needed.

Side effects include, but are not limited to those listed below.

Possible risks include: headache, euphoria, decreased mental and physical awareness and control, dizziness, nausea, and unsteadiness. I consent to regular, monthly treatments as needed.Patients should wait 10 minutes after the last use of PRO-NOX before driving a car or operating any type of machinery.

The procedure may result in the following adverse experiences or risks:
• Mild to moderate discomfort is typical during treatment.
• Mild to significant erythema (redness) and mild to moderate edema (swelling) developing
during or within several minutes of treatment are expected treatment side effects.
• Mild flareups of inflammatory acne lesions are common after treatment.
• Temporary mild skin dryness is common after treatment.
• Mild to moderate blisters developing during or within several hours of treatment are uncommon but have been reported.
• Mild crusting or scabbing is rare but has been reported as typically following blistering.
• Brown darkening of the skin (hyperpigmentation) can occur either following blistering or
crusting or as a result of inflammation during the recovery period.
• Transient texture changes are rare and usually resolve with time.
• Scarring is a rare occurrence, but it is a possibility whenever the skin’s surface is disrupted.
• Lightening or loss of skin pigment (hypopigmentation) is very rare.

I understand Emface/Exion requires a series of 4-6 treatments for full results and I’m responsible to complete the full treatment. I agree to stay hydrated during the treatment. I agree that I don’t have metal implants under the area/surrounding that is being treated. It’s recommended to use medical skin care to achieve & maintain the best results.