Forms

I understand that COVID-19 has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to be spread by person-to-person contact. I understand that public health agencies recommend social distancing as part of the ongoing efforts to reduce the spread of the infection within the community.

I recognize that the medical providers and staff at my clinic are closely monitoring the situation and have put into place reasonable preventative measures as recommended by local health authorities targeted to reduce the spread of COVID-19. Despite these protocols and given the nature of this novel coronavirus, I understand there is an inherent risk of becoming infected with COVID-19 by proceeding with this elective treatment and/or by attending an appointment at the clinic. I agree not to commence any actions or claims against Dr. Rotstein or her clinics, Sherlase Clinic & Spa or any of the staff for any damages related to contracting COVID-19.

I understand that even if I have been tested for COVID-19 and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted the virus after the test was done. I understand that if I have a COVID-19 infection and even if I am not displaying any symptoms, proceeding with this elective treatment could possibly lead to a higher chance of complications.

I understand that COVID-19 may cause additional risks which may not be currently known or fully understood, in addition to the usual risks of the treatment itself as outlined in the regular consent forms. I understand the potential risks, including but not limited to the possible short-term and/or long-term complications related to COVID-19 and I would like to proceed with my treatment.

I understand that I am opting to undergo an elective procedure that is not urgent or medically necessary. I am satisfied with the information I have received from the clinic staff and/or my health care provider, I have no further questions and I consent to the scheduled procedure.

I understand that COVID-19 has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to be spread by person-to-person contact. I understand that public health agencies recommend social distancing as part of the ongoing efforts to reduce the spread of the infection within the community.

I recognize that the medical providers and staff at my clinic are closely monitoring the situation and have put into place reasonable preventative measures as recommended by local health authorities targeted to reduce the spread of COVID-19. Despite these protocols and given the nature of this novel coronavirus, I understand there is an inherent risk of becoming infected with COVID-19 by proceeding with this elective treatment and/or by attending an appointment at the clinic. I agree not to commence any actions or claims against Dr. Rotstein or her clinics, Sherlase Clinic & Spa or any of the staff for any damages related to contracting COVID-19.

I understand that even if I have been tested for COVID-19 and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted the virus after the test was done. I understand that if I have a COVID-19 infection and even if I am not displaying any symptoms, proceeding with this elective treatment could possibly lead to a higher chance of complications.

I understand that COVID-19 may cause additional risks which may not be currently known or fully understood, in addition to the usual risks of the treatment itself as outlined in the regular consent forms. I understand the potential risks, including but not limited to the possible short-term and/or long-term complications related to COVID-19 and I would like to proceed with my treatment.

I understand that I am opting to undergo an elective procedure that is not urgent or medically necessary. I am satisfied with the information I have received from the clinic staff and/or my health care provider, I have no further questions and I consent to the scheduled procedure.

All appointments must be cancelled 24-hours prior to treatment BY PHONE (905.201.8005) or a fee will be charged. For all prepaid packages, failure to cancel 24-hours in advance will result in loss of treatment. SHERLASE WILL NOT ISSUE REFUNDS FOR ANY PRODUCT OR SERVICE but are happy to credit your account. I consent to receiving appointment reminders, information and promotions via email, phone or text.

I clearly understand that:

The hyaluronic acid (HA) filler to be injected is of non-animal origin.

HA is injected via a syringe with a needle and/or cannula into the dermis or deeper structures to temporarily correct fine lines, wrinkles, folds, and sagging or to contour the face, or to temporarily increase the volume of the lips.

No guarantees can be made regarding the final cosmetic result in my case.

The duration of correction varies depending on the product injected, the areas that is injected, the amount of product that is injected as well as individual patient characteristics but ranges from 6 months to 2 years.

I may need additional treatments, at an additional cost, to achieve the desired cosmetic outcome.

In some cases, surgery is a more appropriate treatment option and if this is the case, I may have a suboptimal result with the filler. I agree that my doctor has counselled me about this and I am choosing to proceed with filler injection despite this counselling.

The HA filler has been premixed with an anaesthetic (lidocaine) by the manufacturer.

I clearly understand that this procedure is not medically necessary and that there are some potential side effects which include and may not be limited to the following:

Inflammatory reactions such as redness, swelling, pain, or pressure and which may persist for a few weeks;

Nodules may develop at the injection site or elsewhere. These reactions may be immediate or delayed. They are usually temporary but may rarely be permanent and/or require additional treatment, possibly at an additional cost;

Nerve injury, infection, and allergy;

Rare cases of filler product being injected in blood vessels potentially leading to necrosis (tissue death) and scarring. There have also been rare cases of blindness and stroke reported after the use of HA fillers;

Bruising (mild or significant) and lasting from a few days to a few weeks is possible. This risk is increased if using a product that acts as a blood thinner (eg aspirin, advil, alcohol, and certain vitamins/supplements).

I understand that in some cases of undesired cosmetic effects or in the event of a serious side effect as described above, I may need to be treated with hyaluronidase (an enzyme that breaks down the filler). I further understand that this enzyme is associated with a risk of allergy, including anaphylaxis and if this occurs, I consent to treatment of the allergic reaction.

I understand that I cannot be treated with HA filler if:
I am pregnant or breastfeeding; I have an active infection (including viral infections and cold sores); I have a history of autoimmune disease; I am receiving immunotherapy treatments; I have a known hypersensitivity to hyaluronic acid (HA) or hyaluronidase

I have answered all questions regarding my medical history, including cosmetic surgical and non-surgical history truthfully. I understand that omission of this information may lead to undesirable outcomes. I have discussed the risks/benefits of HA injections with my health care professional and have received satisfactory answers. I agree that this consent constitutes full disclosure.

It is understood the Hyperhidrosis form must be downloaded, completed and brought in on the day of appointment or earlier.

I understand I must supply this completed form and have it signed by Dr. Jennifer Rotstein prior to your procedure in order for insurance processing.

I Duly authorize a Sherlase Clinic LTD. Technicians to perform laser or Intense Pulse Light procedures for the removal of unwanted hair.

I understand that epilating with selective laser light has been shown to be a safe alternative method used for removing unwanted hair rather than shaving, waxing, chemical epilating and electrolysis. I have been specifically advised that:

Most Patients achieve delayed hair re-growth or a permanent reduction In hair growth of the treated area. Some patients experience little to no re-growth after 5-6 treatments and others require 6-10. The amount of treatments and level of success vary from person to person.

I authorize Dr. Jennifer Rotstein and/or her nurse(s) to perform neurotoxin injections in order to reduce the appearance of my facial wrinkles in the treated areas. I understand that the neurotoxin relaxes the muscles under the skin and therefore reduces the amount of wrinkling caused by muscular contraction. I understand that tiny amounts of neurotoxin will be injected into the muscles under my skin and that this will cause my muscles to temporarily relax for approximately 3-4 months. Although results are commonly predictable and provide a good outcome, I have been informed that the practice of cosmetic medicine is not an exact science and that no guarantees can be made concerning expected results in my case.

I also understand that it can take up to 14 days for the full effect to occur although the benefits may begin to develop within the first few days. I understand that there will be a reduction of muscle movement/wrinkling in the treated areas but that there is no guarantee that wrinkles will completely disappear.

I understand that this procedure is not medically necessary and that there are some potential side effects which include but may not be limited to the following:

• Headaches, swelling, bruising and tenderness in the treated areas;


• Neurotoxin spread resulting in unwanted effects on distant muscles/organs or asymmetry;


• Drooping eyelid or eyebrow or lip;


• Allergy or infection;

I understand that some of these potential side effects may require additional treatments at the discretion of my doctor (for example, eye drops to correct a droopy eyelid) and that these treatments will be my financial responsibility and I consent to the use of such treatments.

I have received post-treatment instructions and I agree to follow the recommendations of my doctor/nurse. Specifically, I will not manipulate the treated area, lie down, or engage in strenuous activity for 4 hours after the injection. I understand that failure to comply with these instructions may result in undesired and unpredictable effects of my treatment.

I understand that I cannot be treated with neurotoxin if I am pregnant, breastfeeding, have a history of hypersensitivity to any neurotoxin, or if I have a history of neuromuscular disease. I understand that I cannot receive Dysport injections if I have a history of allergy to cow’s milk protein.

I agree that this consent constitutes full disclosure.

I consent to the injection of a neurotoxin as selected by my health care professional and as discussed with me.

POSSIBLE ADVERSE EVENTS:
The following may occur post treatment:

• • Hyperpigmentation/hypopigmentation (to minimize this the proper post procedure must be followed)


• • Allergic Reaction: I also understand that exposure to different ingredients found in the treatment and associated home care products may result in an allergic reaction. If an allergic reaction occurs, I will immediately discontinue use of all professional treatments and AlumierMD home care products and consult my physician


• • Contact dermatitis, inflammation (redness), edema (swelling), skin irritation (itchiness)


• • Temporary sensation of heat and itchiness immediately following treatment

PEELING:
I understand that I may or may not actually peel and that each treatment is individual. I understand that the degree of peeling does not correlate with the degree of improvement.

CONDITIONS OF TREATMENT:
I agree to refrain from the following activities for 14 days post treatment:

• • Sun or tanning bed exposure


• • Microdermabrasion


• • Laser hair removal
• • Photofacials


• • Chemical peels


• • Laser I RF skin treatments




I agree to refrain from the following activities for 7 days post treatment:



• • Waxing, threading, and all use of other depilatories


• • Neurotoxin injections (eg. Botox, Dysport)


• • Dermalfiller injections


• • Use of retinoids


• • Use of mechanical exfoliants


• • Use of topical AHA or BHA and all other exfoliant topical skin care products


• • Use of sunless tanning products


• • Acne topical treatments




I agree to disclose the names of all prescription and non-prescription products that I am using.

I agree to follow all post-procedure protocols recommended by my physician/skin care professional.

I agree to use a professional medical grade sun protection product (SPF 30 or higher) for a minimum of 14 days
post treatment.


LIMITATIONS TO TREATMENT:
I understand there are no guarantees as to the results of this treatment due to many variables including age, skin condition, sun damage, smoking, climate, etc. I understand that this treatment is cosmetic and that no medical claims are expressed or implied. I understand that to achieve maximum results, I may require several treatments.

COMPLICATIONS:
I understand that although complications are rare, they do occur and prompt treatment is necessary. In the event of a complication, I will contact the physician/skin care professional who performed my treatment I hereby certify that all the information that I have provided has been accurate and truthful. I acknowledge the above adverse events, limitations and complications. I further acknowledge that these adverse events, conditions, limitations and complications have been explained and that I accept and consent to treatment. I agree to follow all post treatment care instructions provided to me. I acknowledge that I have been provided with adequate time to read, understand and accept the above adverse events, limitations and complications.

I hereby state that, to the best of my knowledge, my answers to the above questions are correct.

I agree and consent to assessment and treatment. I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment.

Treatments may be covered by extended health care plans. I understand that it is my responsibility to confirm the exact details of my coverage.

I understand that the massage therapist is providing massage therapy service within their scope of practice as defined by the CMTO, College of Massage Therapists of Ontario. I hereby consent for my therapist to treat me with massage therapy for the above noted purposes including such assessments, examinations and techniques that may be recommended, by my therapist. I acknowledge that the therapist is not a physician and does not diagnose illness disease, or any other physical or mental disorder. I clearly understand that massage therapy is not a substitute for a medical examination. It is recommended that I attend my personal physician for any ailments that I may be experiencing. I acknowledge that with any treatment, there can be risks and those risks have been explained to me and I assume those risks. I acknowledge and understand that the therapist must be fully aware of my existing medical conditions. I have completed m medical history form as provided by my therapist and disclosed to the therapist all of those medical conditions affecting me. It is my responsibility to keep the massage therapist updated on my medical history. The information I have provided is true and complete to the best of my knowledge. I authorize my therapist to release or obtain information pertaining to my condition(s) and/or treatment to/from my other caregivers or third-party payers, only when necessary and only with a prior verbal request. I have read the above noted consent and I have had the opportunity to questions the contents and my therapy. By signing tis form, I confirm my consent to treatment and intend this consent to cover the treatment discussed with me and such additional treatment as proposed by my therapist from time to time, to deal with my physical condition and for which I have sought treatment. I understand that at any time, I may withdraw my consent and treatment will be stopped.

PLEASE REVIEW THE FOLLOWING NEW PROTOCOLS IN ORDER TO BEST PREPARE FOR YOUR APPOINTMENT.

1. Please arrive ON TIME for your appointment. In order to minimize staff and patient exposure, you will not be permitted to wait in the waiting room. You will have to wait in your car or outside the clinic until your scheduled appointment time before you will be let into the clinic. Once you arrive, please call us at 905.201.8005 and we will advise you when it’s clear to enter the clinic.

2. Please come ALONE to your appointment as we can only allow 2 people in the treatment room (the health care provider and the patient).

3. Please come to the appointment wearing your own mask or face covering from home. If your treatment is going to include having filler or microneedling, please bring a second, clean mask to put on after the treatment to minimize contamination and potential infection.

4. Please come to the appointment with a CLEAN FACE, free of any makeup, tinted moisturizer or sunscreen.

5. Please only bring in with you the bare essentials for the appointment (payment method, keys). Please leave all non-essential items in your car, including your cell phone.

6. Please be advised that we will take your temperature upon your arrival to the clinic with a touchless infrared thermometer and if the reading is greater than 37.5, you will be sent home and asked to rebook your appointment.

7. You will be expected to use hand sanitizer immediately when you arrive to your appointment and throughout the appointment. These are provided at various locations throughout the clinic.

8. In order to decrease droplet exposure for you and the clinic staff, we will need to keep talking to a minimum during your appointment. This is also in keeping with the Ministry of Health mandate to limit exposure time for in-person patient appointments. Please feel free to ask all questions prior to your appointment. If you are a new patient, we will be doing consults virtually, unless you know that you will definitely proceed with your treatment on the same day as the consult and you meet all of the requirements to be able to do so.

9. For payment options, the credit card/debit machine is available and is cleaned before and after each use.
10. Finally, follow-up appointments will be done either virtually or via email communication. For botox treatments, these follow-ups will occur 2 weeks after the treatment appointment. For filler treatments, these follow-ups will occur 4-6 weeks after the treatment appointment.

Of course if there are any significant concerns about your treatment, do not hesitate to get in touch with us sooner.