1314 S. King Street, #604 Honolulu, HI 96814

(808) 546-9544

CONSENT TO NEUROTOXIN

I hereby consent to and authorize Jennifer M. Lee FNP, LLC, a Hawaii limited liability company dba Jen Medical Aesthetics Beauty & Wellness to perform Neurotoxin.

This is not just a formality – it’s a record of your decision to consent to a procedure having considered the risk of both positive and negative outcomes and medical risks listed below, and the impact they may have on your well-being.

Please initial on the right that you have read, understood, and discussed as required with your clinician.

What is being injected? Botulinum Toxin is purified protein produced by bacterium clostridium botulinum. The product causes muscle relaxation and suppresses sweating for 2-6 months on average (with wide variation between individuals) by temporarily disrupting nerve activity to muscles and sweat glands.

By signing this form, you agree and understand that some treatment areas are given off label as deemed appropriate by prescribing clinician.

By checking these boxes, I acknowledge the following: *

What are the side effects and risks? • Transient headache, swelling, bruising, bleeding, pain, twitching, itching, puffiness/edema around the eyes or numbness or other changes in sensation. • Allergies including anaphylaxis is possible but very rare. • Asymmetry (unevenness) • Temporary drooping of facial features, including eyebrows, cheeks, and mouth. • Dry eyes • Double or blurred vision • The theoretical risk of complications unique to certain individuals or so far unknown.

Interactions: I have disclosed my medical and drug history to my clinician and am aware that many medications increase the risk of bruising and include but are not limited to Vitamin E, Vitamin C, Ginkgo Biloba, Ginseng, Ginger, Fish Oil, Aleve, Turmeric, Aspirin, Motrin, Plavix, Warfarin, and others.

Limitations and alternative: Occasionally the treatment wear off very quickly or does not work at all. Botulinum Toxin is best at treating dynamic facial lines; those caused by facial muscle activity, lines present at rest may or may not improve and can be unpredictable. I have considered alternatives to treatment, including doing nothing, topical creams, chemical peels, laser treatments, surgical denervation, forehead/brow lift, facelift, or hyaluronic acid treatments and elected that at this time Botulinum toxin is the best option for me.

Follow-up: I understand Touchups should be scheduled at two weeks after treatment, any treatment beyond 2 weeks is considered a new treatment. Any Touchups beyond 5 units will be charged regular pricing.

Dissatisfaction: I understand that with all treatments the actual degree of improvement cannot be predicted or guaranteed. The outcome’s subjective nature means dissatisfaction is a possible outcome regardless of effectiveness of treatment. I understand that the effect of all treatments may gradually wear off and additional treatments may be necessary to maintain the desired effects.

Agreement: By signing this form, you agree that you have read this form carefully and considered the side effects, risks and uncertainty of the outcome and decided the treatment is still in your best interests at this moment in your life. You have discussed all the details of the treatment plan, past treatments and your medical history with your clinician and shared all the information your clinician may need to plan a treatment. You agree that the balance of the benefits and risks to you overall favor the use of botulinum toxin. I understand that the primary treatment side effects and complications is included in the cost of the procedure and therefore no refunds are issued due to any of the above occurring. I understand photographs are taken and stored for 7 years as part of my clinical record.

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