{"id":16,"date":"2020-07-22T00:55:15","date_gmt":"2020-07-22T04:55:15","guid":{"rendered":"http:\/\/myskincareclub.com\/forms\/?page_id=16"},"modified":"2020-07-25T13:24:43","modified_gmt":"2020-07-25T17:24:43","slug":"client-consent-for-dysport-cosmetic","status":"publish","type":"page","link":"https:\/\/myskincareclub.com\/forms\/client-consent-for-dysport-cosmetic\/","title":{"rendered":"CLIENT CONSENT FOR DYSPORT COSMETIC"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"16\" class=\"elementor elementor-16\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-0703c2e elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"0703c2e\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-1b85590\" data-id=\"1b85590\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-85d36b1 elementor-widget elementor-widget-text-editor\" data-id=\"85d36b1\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><b>CLIENT CONSENT FOR DYSPORT COSMETIC<\/b><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b20e25b elementor-widget elementor-widget-text-editor\" data-id=\"b20e25b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Rationale<br \/>I am aware that when a small amount of DYSPORT is injected into a muscle it causes<br \/>weakness of that muscle. This appears in 3-4 days with full effect in 14 days and usually lasts<br \/>four months but can be shorter or longer. Mid, lower face and neck areas are off labels for use<br \/>of DYSPORT. For example: Frown lines between the eyebrows are due to contraction of a small<br \/>muscle, corrugated beneath the inner part of each eyebrow. Injecting Dysport into this muscle<br \/>will relax it causing improvement or disappearance of the frown lines.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-66c35f5 elementor-widget elementor-widget-text-editor\" data-id=\"66c35f5\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Results and Postoperative Care<\/p>\n<ol>\n<li>I understand that I will not be able to move the treated muscle\/s while the injection is effective but that this will reverse itself after a period of months at which time re-treatment is appropriate.<\/li><li>I understand that I must stay in the erect posture and that I must not manipulate the area&nbsp;<span style=\"font-size: inherit; text-align: inherit; letter-spacing: -0.015em;\">of the injection site for the four hour post-injection period.<\/span><\/li><\/ol>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-56d0061 elementor-widget elementor-widget-text-editor\" data-id=\"56d0061\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Risk and Complications<br \/>DYSPORT treatment of frown lines can cause minor temporary droop of one eyelid in\u00a0approximately 2% of injections. This usually last 2-3 weeks. Occasional numbness of the\u00a0forehead lasting 2-3 weeks, bruising and transient headache have occurred. In a very small\u00a0number of individuals, the injection does not work as satisfactorily or for as long as usual.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-654214a elementor-widget elementor-widget-text-editor\" data-id=\"654214a\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Photographs<br \/>I authorize the taking of clinical photographs, I understand my identity will be protected.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-5c6852f elementor-widget elementor-widget-text-editor\" data-id=\"5c6852f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Payment and Cancellation Policy<br \/>Payment is my responsibility and is due in full at the time of service. I understand that I will incur\u00a0a fee of $100 for cancellation of any scheduled appointment without 24 hours notice.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-9cc12f3 elementor-widget elementor-widget-text-editor\" data-id=\"9cc12f3\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Pregnancy and Neurologic Disease<br \/>I am not aware that I am pregnant or nursing nor that I have any significant neurologic disease.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-8174dac elementor-widget elementor-widget-text-editor\" data-id=\"8174dac\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>I understand I will have the DYSPORT injected by Daniela Bobsin, RN.\u00a0\u00a0I have read the above and understand it. My questions have been answered satisfactorily by the\u00a0Health Care Provider. I accept the risks and complications of the procedure.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-53acfad elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"53acfad\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-35d2b05\" data-id=\"35d2b05\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-cb6d0f5 elementor-widget elementor-widget-wp-widget-frm_show_form\" data-id=\"cb6d0f5\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wp-widget-frm_show_form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"frm_form_widget\"><div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_3_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_clientconsentfordysportcosmetic\" >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Client Consent for DYSPORT Cosmetic<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"3\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_3\" id=\"frm_hide_fields_3\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"clientconsentfordysportcosmetic\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_3\" name=\"frm_submit_entry_3\" value=\"7304d70deb\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/forms\/wp-json\/wp\/v2\/pages\/16\" \/><div id=\"frm_field_47_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_c51lg\" id=\"field_c51lg_label\" class=\"frm_primary_label\">Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_c51lg\" name=\"item_meta[47]\" value=\"\"  style=\"width:40%\" data-invmsg=\"Text is invalid\" class=\"auto_width\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_48_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_afaf4\" id=\"field_afaf4_label\" class=\"frm_primary_label\">Date\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_afaf4\" name=\"item_meta[48]\" value=\"\"  style=\"width:40%\" maxlength=\"10\" data-invmsg=\"Date is invalid\" class=\"frm_date auto_width\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_49_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_5oke7\" id=\"field_5oke7_label\" class=\"frm_primary_label\">Signature\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"sigPad\" id='sigPad49' style=\"max-width:400px;\">\n\t<div class=\"sig sigWrapper\" style=\"height:150px;border-color:#BFC3C8;--bg-color:#ffffff;--active:#579AF6;--inactive:#eaeaea;--active-text:#ffffff;--inactive-text:#3f4b5b;--button-margin:22px;--button-size:20px;--button-padding:10px;--button-side-margin:22px;--icon:20px\">\n\n\t\t<ul class=\"sigNav\">\n\t\t\t\t<li class=\"drawIt\">\n\t\t\t\t\t<a href=\"#\" class=\"frm-active-sig-type\" title=\"Draw It\" aria-label=\"Draw It\">\n\t\t\t\t\t\t<svg  viewBox=\"0 0 22 20\" class=\"frmsvg\">\n\t<title>signature<\/title>\n\t<path d=\"M19.7 2.2A3.5 3.5 0 0 0 14 1.1L1.7 13.4a1 1 0 0 0-.3.4l-1.3 5a.9.9 0 0 0 0 .5 1 1 0 0 0 1 .6l5-1.3c.2 0 .4-.1.5-.3L18.9 6a3.5 3.5 0 0 0 .7-3.8zm-6.8 2.6L15.2 7l-8.6 8.7-2.4-2.4zm-10.7 13l1-3.3L5.4 17zM18 4.2l-.4.5L16.3 6 14 3.7l1.3-1.3A1.7 1.7 0 0 1 18 3.6l-.1.6zM9 17.9h11v1H9v-1z\"><\/path>\n\n<\/svg>\t\t\t\t\t<\/a>\n\t\t\t\t<\/li>\n\t\t\t\t<li class=\"typeIt\">\n\t\t\t\t\t<a href=\"#\" class=\"\" title=\"Type It\" aria-label=\"Type It\">\n\t\t\t\t\t\t<svg  viewBox=\"0 0 22 20\" class=\"frmsvg\">\n\t<title>keyboard<\/title>\n\t<path d=\"M20.6 2.5H2c-1 0-1.9.8-1.9 1.9v11.2c0 1 .8 1.9 1.9 1.9h18.7c1 0 1.9-.8 1.9-1.9V4.4c0-1-.8-1.9-1.9-1.9zm.3 13.1c0 .2-.1.3-.3.3H2a.3.3 0 0 1-.3-.3V4.4c0-.2.1-.3.3-.3h18.7c.2 0 .3.1.3.3v11.2zm-14.3-5V9.4c0-.3-.2-.5-.4-.5H5c-.3 0-.5.2-.5.5v1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0V9.4c0-.3-.2-.5-.5-.5H9c-.3 0-.5.2-.5.5v1c0 .3.2.5.4.5H10c.3 0 .5-.2.5-.5zm3.7 0V9.4c0-.3-.2-.5-.4-.5h-1.1c-.3 0-.5.2-.5.5v1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0V9.4c0-.3-.2-.5-.5-.5h-1c-.3 0-.5.2-.5.5v1c0 .3.2.5.4.5h1.1c.3 0 .5-.2.5-.5zM4.8 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class=\"clearButton\"><a href=\"#clear\">Clear<\/a><\/div>\n\n\t\t<input type=\"hidden\" name=\"item_meta[49][output]\" class=\"output\" value=\"\" \/>\n\t<\/div>\n<\/div>\n\r\n    \r\n    \r\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t<div id=\"frm_field_236_container\">\n\t\t\t<label for=\"field_whw3s\" >\n\t\t\t\tIf you are human, leave this field blank.\t\t\t<\/label>\n\t\t\t<input  id=\"field_whw3s\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[236]\" value=\"\"  \/>\n\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"xgbTmpRrvI+5BluaOEpLInjikL1AQE+vPg0XanqrsPzq9oXrtQPMpeG4FaMsnd4G\" \/><div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"  >Submit<\/button>\r\n\r\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\n<\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>CLIENT CONSENT FOR DYSPORT COSMETIC RationaleI am aware that when a small amount of DYSPORT is injected into a muscle it causesweakness of that muscle. This appears in 3-4 days with full effect in 14 days and usually lastsfour months but can be shorter or longer. Mid, lower face and neck areas are off labels [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-16","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/pages\/16","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/comments?post=16"}],"version-history":[{"count":8,"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/pages\/16\/revisions"}],"predecessor-version":[{"id":99,"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/pages\/16\/revisions\/99"}],"wp:attachment":[{"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/media?parent=16"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}