American Board of
Otolaryngology and American Board of Facial Plastic & Reconstructive Surgery
American Board of
Ophthalmology with specialization in Ophthalmic Plastic & Reconstructive
Surgery
American Board of
Dermatology with specialization in Cosmetic or Dermatologic Surgery
My physician is a member of one or more of these groups:
American Society for
Aesthetic Plastic Surgery
American Society of Facial
Plastic and Reconstructive Surgeons
American Society of
Ophthalmic Plastic Surgeons
American Society of
Plastic Surgeons
American Society for
Dermatologic Surgery
If a nurse or physician’s assistant is injectingall of these things are true:
I have first seen a board certified
physician whose specialty is defined above
The
laws regarding cosmetic injections in the state where I will be injected are
defined to me by the physician
I know the prescribing/supervising
physician will be during my injections
The Nurse demonstrated competency in performing cosmetic injections with
certificate issued by the supervising professional specialty
organizations:
American Society for Aesthetic Plastic Surgery
American Society of Facial
Plastic and Reconstructive Surgeons
American Society of
Ophthalmic Plastic Surgeons
American
Society of Plastic Surgeons
BRAND
INFORMATION:
All of these statements are true:
My injector has gone over
the FDA approved cosmetic injectable recommended for me
My injector has shown me
the FDA packaging identifying the cosmetic injectable that will be injected
My injector has
written on my informed consent documents and in my medical chart the FDA
approved cosmetic injectable
SAFETY INFORMATION:
All of these statements are true:
My injections are
being performed in a medical office, or a medical spa whose medical director
meets all of the statements above about my physician
My injections are
being performed at a time when I or my injector are not intoxicated or under
the influence of a controlled substance
I feel safe and at
ease with my injector
My injector has
taken me through the informed consent process defining where I will be
injected, with what, and what the potential risks or complications may be as
well as defined alternative treatments that may meet my cosmetic goals
I will follow all
the post-treatment instructions I am given and follow-up with my doctor or
injector as prescribed
BEAUTY INFORMATION:
All of these statements are true:
I can clearly define the
areas of my facial appearance I hope to improve with cosmetic injectables
My injector has analyzed
the areas of my facial appearance I hope to improve with cosmetic
injectables, and my facial appearance overall to recommend the options
available to me to meet my goals
I understand the expected
duration of my results, and that if I do not repeat injections, my facial
appearance will return to it’s prior condition
I understand that minor
swelling, bruising or redness for a few days after my injections is a normal
occurrence that can be camouflaged with cosmetics