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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_19_библиотеки_им_акад_М_И_Перельмана
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264 Appendix 1
https://t.me/medicina_free
Previous Hospitalizations/Operations:_____________________________________________________
____________________________________________________________________________________
Have you had plastic surgery or other surgery to your face/neck area and if so when:________________
____________________________________________________________________________________
WOMEN: Are you pregnant, trying to get pregnant, or lactating? ______________________________
BOTOX
Have you had Botox injections before? ____________________ Last treatment: ___________________
What areas?_________________ Were you happy? If not, explain: _____________________________
Have you ever had eyelid/eyebrow droop after Botox? _______________________________________
Do your eyelids droop without sleep? _____________________________________________________
Do you show a lot of upper eye lid when eyes are open?_______________________________________
DERMAL FILLERS
Have you had any Dermal Fillers procedures before? ____________ Last Treatment? _______________
What areas was it placed? ______________________________________________________________
CURRENT SKIN CARE REGIMEN
What products are you currently using on your face? _________________________________________
Are you happy with your current products? Yes or No? _______________________________________
Do you use a Clarisonic? Yes or No? ___________________ What would you like to improve with your
skin care regimen? ____________________________________________________________________
I understand the information on this form is essential to determine my medical and cosmetic needs and
the provisions of treatment. I understand that if any changes occur in my medical history/health I will
questionnaire. I acknowledge that all answers have been recorded and truthfully and will not hold any
staff member responsible for any errors or omissions that I have made in the completion of this form.
Patient Signature:________________________________________________Date:________________
Provider Signature:______________________________________________Date:__________________
@2013 Surface Medical Esthetics, PLLC Aesthetic Medical Intake Page of Patient Initials_______23
IN HOUSE USE ONLY:
https://t.me/medicina_free
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265Appendix 1
Ye s N o
@2013 Surface Medical Esthetics, PLLC Aesthetic Medical Intake Page of Patient Initials_______33
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https://t.me/medicina_free
APPENDIX 2
https://t.me/medicina_free
Pre care guidelines email
Botox pre care guidelines
Please arrive on the day of your appointment with a clean face, free of any
lotions and or makeup, even eye makeup. We recommend showing up
about 10 min prior to your appointment time so that you can fill out your
necessary treatment consents and for us to review your medical history.
After consents are signed, a team member will take your pictures to document the skin’s health and appearance pre-treatment. Once you are
prepped and ready; Tara will begin your treatment, which will take about
10 min.
No dental work within 2 weeks of your treatments.
Bring a hair tie to pull your hair back from your face.
Take Arnica tabs to minimize bruising.
The healthier you eat, the better all-around.
If you feel ill, you must reschedule your appointment.
We look forward to working with you on your esthetic journey.
Want us to let you in on a little secret?
One helpful little trick to improve your Botox (neuromodulator)
treatment is being sure you have adequate Zinc in your system. All neuromodulators require Zinc at the nerve terminal so that the neuromodulator
can bind to it most effectively. If you feel that your neuromodulation isn’t as
stiff or strong as it has been in the past and we are using the same dose …
consider adding zinc supplements 5 days prior to treatment and 5 days
post-treatment.
Love Tara
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https://t.me/medicina_free
APPENDIX 3
https://t.me/medicina_free
Post care guidelines email
Botox after care instructions
We want to thank you for choosing the team at DCCM™ to help meet your
esthetic goals. Now that you have taken the plunge with your Botox
(neuromodulator) treatment, we want to remind you about your aftercare
instructions. This way, you can maximize the potential of your treatment.
Please refrain from the use of hats, helmets, and visors, as well as facials and
massages. The Botox (or neuromodulator) that we put in the muscle needs to
set up in the muscle in order to take effect. Restricting blood flow and putting
pressure on the muscles in the treated area can cause an unwanted shift in the
product and sometimes result in an unwanted outcome.
Botox (neuromodulator) takes 2 full weeks to kick in. As the treatment
begins to settle, you may want to give us a call to have us add a touch more in
that time frame. We will not add more in the treated area within that 2 weeks
time frame. Trust in the process that it will all settle out within 2 weeks.
Should you need a slight touch up at 2 weeks, we welcome you to come
back in for evaluation. If you would like to add more, we request that this
be done on day 14–19 so that you can get the most out of your treatment.
We honor all of our work, but in order to do so, we require a follow-up visit
on day 14–19 after your initial Botox (neuromodulator) appointment. Our
goal is to do our best to meet your goals. We really encourage and love to see
all of our clients back at 2 weeks to be sure your treatment is perfect.
If you found yourself with a bit of a bruise, we recommend using Arnica
gel and tablets. Each product formulation is different; therefore, we would
advise you to follow the specific directions on the back of the branded bottle
you purchase. These can be found at the whole foods store right in Hampton
or at most pharmacies and grocery stores.
Want us to let you in on a little secret?
269
270 Appendix 3
https://t.me/medicina_free
One helpful little trick to improve your Botox (neuromodulator) treatment is ensuring you have adequate Zinc in your system. All neuromodulators require Zinc at the nerve terminal so that the neuromodulator can
bind to it most effectively. If you feel that your neuromodulator is not as
stiff or strong as it has been in the past and we are using the same dose …
consider adding zinc supplements 5 days before treatment and 5 days
post-treatment.
We want to thank you for choosing the team here at DCCM™. As always,
pleasecall us with any questionsor concernsthat may arise.We are here for you
and want you to feel confident in the process just as much as in your skin!
Our number is (603)-783-1087.
Between the hours of 8 AM and 4 PM you may call the office number.
However, if you feel you have a pressing question that can not wait until normal business hours; please text (603)-783-1087 so we can assist you. We hope
you enjoy your results and look forward to seeing you again at your next visit.
Love Tara
APPENDIX 4
https://t.me/medicina_free
Neuromodulation consent
I understand certain Neuromodulation are FDA-approved for treatment of
rhytids (wrinkles) located between the eyebrow, also known as the Glabella
region. Other areas are commonly treated with neuromodulation, which
have not been FDA-approved, and this is considered “off-label use.” Neuromodulation can relax the muscles on areas of the face and neck which
cause wrinkles associated with facial expressions. I understand that neuromodulation cannot improve sagging skin or wrinkles caused by aging or
sun damage and understand they are unrelated to muscle contraction. Treatment with neuromodulation can cause facial expression lines or wrinkles to
essentially disappear. The primary effect of the neuromodulation injection is
on the nerve terminal and the secondary effect is on the muscle. Areas most
commonly treated are: (a) glabella area of frown lines, located between the
eyebrows; (b) crow’s feet (outside areas of the eyes); and (c) forehead wrinkles; however, neuromodulation may also be used in other facial areas. The
Neuromodulation is reconstituted to a very controlled solution and, when
injected into the muscles with a very thin needle, it is almost painless.
I understand patients may feel a slight burning sensation while the solution
is being injected. The procedure takes about 15–20 min and results generally
last 3–4 months. In some individuals, the results of one treatment may last
shorter or longer. With repeated treatments, the results may also tend to
last longer.
Risks and complications
It has been explained to me that there are certain inherent and potential risks
and side effects with any invasive procedure. In this specific instance, such
risks include, but are not limited to:
1. Post treatment discomfort, swelling, redness, and bruising;
2. Double vision;
3. Weakened tear duct, rarely;
4. Post treatment bacterial and/or fungal infection requiring further
treatment;
5. Allergic reaction;
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272 Appendix 4
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6. Minor temporary droop of eyelid(s), eyebrow (s), or corner of the mouth
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.
Neuromodulation pre treatment instructions
It is prudent to follow some simple guidelines before treatment that can
make all the difference between a fair result or great result, by reducing
some possible side effects associated with the injections. We realize this is not
always possible; however, minimizing these risks is always desirable.
• Avoid alcoholic beverages at least 24 h prior to treatment (alcohol
may thin the blood increasing the risk of bruising).
• Avoid anti-inflammatory/blood thinning medications ideally, for
a period of two (2) weeks before treatment. Medications and supple-
ments such as Aspirin, Vitamin E, Gingo Biloba, St. John’s Wort, Ibu-
profen, Motrin, Advil, Aleve, Vioxx, and other NSAIDS (non-steroidal
anti-inflammatory drugs) are all blood thinning and can increase the risk
of bruising/swelling after injections.
• Schedule your Neuromodulation appointment at least 2 weeks
prior to a special event which may be occurring, i.e., wedding,
vacation, etc. It is not desirable to have a very special event occurring
and be bruised from an injection.
• You will need to reschedule your appointment if you are on antibiotics
for an infection. It is also necessary to rescheduled your appointment if
you have a fever or had a fever in the last 48 h.
Neuromodulation post treatment instructions
The guidelines to follow post treatment have been followed for
years, and are still employed today to prevent the possible side effect of pto-
sis. These measures should minimize the possibility of ptosis almost 98%.
• No straining, heavy lifting, vigorous exercise for 3–4hfollowing
treatment. It is now known that it takes the toxin approximately 2 h
to bind itself to the nerve to start its work, and because we do not
want to increase circulation to that area to wash away the neuromo-
dulation from where it was injected. This waiting period continues to be
recommended by most practitioners.
273Appendix 4
https://t.me/medicina_free
• Avoid manipulation of area for 3–4hfollowing treatment. (For the
same reasons listed above.) This includes not doing a facial, peel, or
micro-dermabrasion after treatment with Neuromodulation for 3 days.
A facial, peel, or micro-dermabrasion can be done in same appointment only if they are done before the Neuromodulation.
• Do not lie down or bend over for 3–4hfollowing treatment. (This
instruction has been employed for years by some practitioners.)
• Avoid having a facial or massage for 3 days.
• Do not wear a hat or helmet for 3 days.
• It can take 2–10 days to take effect and 2 weeks for full effect. It is
recommended that the patient contact office no later than 3 weeks
after treatment if desired effect was not achieved and no sooner than
2 weeks to give toxin time to work.
Makeup may be applied before leaving the office. Some practitioners recommend avoiding Retin-A, Glycolic acid, Vitamin C, and Kinerase for 24 h
to the treated areas.
I have been counseled in these pre and post-treatment instructions and
have been given a written copy of these instructions. All my questions have
been answered to my satisfaction.
Photographs
I authorize the taking of clinical photographs and their use for scientific and
educational purposes both in publications and presentations, as well as any
social media and marketing. I understand my identity will be protected.
Pregnancy, allergies and neurologic disease
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 Neurological disease
(s) including, but not limited to, Myasthenia Gravis, Multiple Sclerosis,
Lambert-Eaton Syndrome, Amyotrophic Lateral Sclerosis (ALS), Parkinson’s. I do not have any allergies to the toxin ingredients or to human albumin and have never had a reaction to a neuromodulation in the past.
Payment
I understand this is an elective cosmetic procedure. I understand and agree
that all services rendered to me will be charged directly to me, and I am
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