Consent Form - LDB Wellness

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Balanced body. Beautiful you.

Balanced body. Beautiful you.

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Name *

First

Last

Email *

Email

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Photography Consent

Use photo concent *

To use my photographs taken before, during, and after treatment or surgery for scientific purposes only, including publication in scientific and professional literature and presentation to medical and scientific audiences.
To use my photographs as examples for other patients interested in similar services. I understand that I may be recognized in these photos even if my name or other identifying information is not included.
To use my photographs for marketing and advertising purposes, including social media. I understand that I may be recognized in these photos, even if they do not contain my name or other identifying details.

Consent to Use of Neuromodulators *

(Botox™, Cosmetic Dysport®, Xeomin®, Nuceiva™) I am aware that injecting a small amount of neuromodulator, a purified natural protein, reduces targeted muscle contractions to soften dynamic facial wrinkles. Full effect may take up to 14 days and usually lasts 3 to 5 months, after which retreatment may be needed.

Post-Injection Instructions *

I understand I must remain upright and avoid pressure on the treated area or intense physical activity for three hours post-injection.

Risks and Side Effects *

Eyelid drooping (in ~2% of cases), lasting 2–3 months. Eyebrow drooping, lasting 2–3 weeks. Forehead numbness, double vision, facial asymmetry, bruising, swelling, headache – all usually temporary. Allergic reactions are extremely rare. Treatment response may vary; results cannot be guaranteed. Dosage may vary by individual muscle structure.

Contraindications *

To my knowledge, I am not pregnant, not breastfeeding, and have no serious neurological or muscular conditions.

Payment *

I understand this is a cosmetic procedure and is not covered; I am financially responsible.

and Injection for

I have read and understand the above. *

My physician has answered my questions. I accept the risks and consent to treatment with the selected neuromodulator

Neuromodulator chosen *

Consent for Injectable Hyaluronic Acid-Based Products *

I understand that hyaluronic acid-based products: Are sterile, non-animal viscoelastic gels. Are injected into the dermis or subcutaneous tissues to correct wrinkles, add lip volume, or reshape facial contours. Typically last 6 to 12 months, depending on skin type, injection site, quantity, and technique.

Possible Reactions After Injection *

Redness, swelling, itching, pain at the injection site. Bruising or hematomas – typically resolve in a few days without treatment. Rare complications (as per literature): necrosis, vision loss, abscess, granulomas, hypersensitivity or allergies, which may require prolonged follow-up care.

COVID-19 Precaution *

Rare cases of facial swelling have been reported post-vaccine in allergic individuals. It is recommended to avoid injections 2 weeks before and after COVID-19 vaccination. I have truthfully answered all questions regarding my medical and aesthetic history. I understand the post-injection instructions and agree to follow them. The treatment has been clearly explained to me, and I consent to injection with the product listed below.

Product(s) used *

Patient Name *

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