Collagenstimulators.pdf 67.24 KB
Name:
Date of birth:
Address:
Phone number:
Email:
Please read this consent form thoroughly.
Please answer all questions.
If you have any uncertainty regarding questions, please discuss with your doctor.
I __________________, hereby consent to undergo a Coallgen Stimulator treatment by ___________________. Collagen stimulators/biostimulators are injectable treatments that stimulate the body’s natural collagen production, leading to gradual and natural-looking improvements in skin texture, elasticity, and volume. Common products include Sculptra and Radiesse.
- The procedure typically takes 30-60 minutes, depending on the treatment area.
- A topical numbing cream or local anaesthetic may be used to minimize discomfort.
- The collagen stimulator is injected into the targeted areas using a fine needle or cannula.
- Results develop gradually over several weeks to months as collagen production is stimulated.
Please answer the following questions. | Yes | No |
1. Do you currently have an infection in the area you would like to treat? | Y | N |
2. Do you have known allergies or sensitivity to chemical peel ingredients? | Y | N |
3. Do you currently have open wound or cuts in the area you would like to treat? | Y | N |
4. Are you currently on isotretinoin (Accutaine)? | Y | N |
5. Have you been on isotretinoin (Accutaine) within the last 6 months? | Y | N |
6. Are you currently pregnant or breastfeeding? | Y | N |
7. Do you have a history of keloid scar formation? | Y | N |
8. Do you have a history of poor wound healing? | Y | N |
9. Do you have diabetes? | Y | N |
10. Are you currently using steroid containing medication? | Y | N |
11. Are you currently using creams/ointment with retinoids or hydroxy acids? (tretinoin, adapalene) | Y | N |
12. Do you have sensitive skin? | Y | N |
13. Do you have psoriasis? | Y | N |
14. Do you have atopic dermatitis? | Y | N |
15. Do you have any connective tissue diseases? | Y | N |
16. Have you had recent facial x-rays? | Y | N |
17. Have you had recent facial surgery? | Y | N |
18. Are you a smoker? | Y | N |
19. Do you currently have cold sores or shingles? | Y | N |
20. Do you often get cold sores or shingles? | Y | N |
Risks and side effects: | ||
While collagen stimulators are generally safe, potential risks and side effects include: | Y | N |
Redness, swelling, or bruising at the injection site | ||
Pain or tenderness | ||
Lumps or bumps | ||
Allergic reactions | ||
Infection | ||
Y | N | |
Asymmetry or irregularities | ||
Formation of nodules or granulomas | ||
Using recommended skin care products. | ||
Not picking or scratching treated skin. |
Pre-Procedure Care
- Inform your healthcare provider of any medical conditions, including allergies and previous adverse reactions to injectable products.
- Discuss any medications you are taking, including prescription and over-the-counter medicines, vitamins, and herbal supplements.
- Avoid alcohol and blood-thinning medications (e.g., aspirin, ibuprofen) for at least 24 hours before the procedure to reduce the risk of bruising.
Post Procedure Care
- Avoid touching or massaging the treated areas for at least 24 hours.
- Avoid strenuous exercise, exposure to extensive sun or heat, and alcoholic beverages for 24 hours post-treatment.
- Apply ice packs to reduce swelling if needed.
- Follow any additional post-treatment instructions provided by your healthcare provider.
Financial Responsibility: I understand that I am financially responsible for the chemical peel treatments sessions as discussed with the doctor.
Consent:
I have read and understand the above information about collagen stimulator/biostimulator treatment. I have discussed the procedure with my healthcare provider and have had all my questions answered to my satisfaction. I understand the risks and benefits associated with collagen stimulator/biostimulator treatment and agree to proceed with the treatment.
By signing this form, I consent to receive collagen stimulator/biostimulator injections from Dr. BB Crook at Arcabee Aesthetics.
Signature: ______________________________
Date:________________
Signature of Healthcare Provider: ________________________
Date: _______________