Ottawa / Kingston Cosmetic Institute

www.ottawa cosmetic institute.com

www.kingston cosmetic institute.com

Phone (613) 532-0900

Initial Consultation

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Do you have any Medical Problems? Yes No If Yes complete “General Medical History” form

Do you take any medications? Yes No If Yes complete “General Medical History” form

Have you had any previous cosmetic treatments? Yes No If Yes complete “Cosmetic History” form

List Any Allergies. ____________________ _________________ ________________ _______________

Medical History

Do you have any history of: (Circle all that apply) 1.Diabetes 2.Heart Disease 3.Stroke 4.Skin Disease (eg Keloids, Recurrent Cold Sores, Abnormal Healing / Scarring) 5.Herpes 6.*Back Pain 7.*Headaches 8.Autoimmune Disease (eg Lupus, Rheumatoid Arthritis, Hypersensitivity Reactions ) 9.Bleeding Disorders 10.Accutane use: If YES please provide details below. If insufficient space pleases complete “General Medical History” form:

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________________________________________________________________________________________________________* Some Ottawa / Kingston Cosmetic Institute treatments used for these conditions may be reimbursable.

What are you hoping for from this appointment? Please use diagram on reverse if applicable.____________

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______________________________________________________________________________________________________ ** IMPORTANT – PLEASE READ ** I certify that all the above information is correct and complete. I have read, understand and agree to the “payment policies” on the website.

Patient Signature: ________________________________________ Date: ____ / ____ / ____

D M Y

Dr. L.A. Waldron MD, CCFP., FCFP. Last Updated 5-Jul-20


Initial Consultation Information

Any other comments? _________________________________________________________________________________________________________

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Office Use Only Below This Line:

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Plan: a. Advised X 4* Other__________________________________________

b. Book/Offer Tx/FU in/on _______/________/_________for:

1. Botox/Dysport GB FH Oth ________________ _______________________________________________

2. R Pfl for: NL FH UL Oth_________

3 Other comments

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* Advised Re Risks/Consent, Payment Policies, Pre/Post Tx Proc.

Dr. L.A. Waldron MD, CCFP., FCFP. Last Updated 5-Jul-20

  • Botox®/Dysport® for Chronic Neck, Back and/or Muscular Pain

    When Botox/Dysport® is used to treat chronic neck, back and/or muscular pain the cost of the medication and treatment may be reimbursable. Check with your third party health insurance (i.e. Blue Cross, employee health plans etc.), to find out if you are covered.


    Formal studies of patients with chronic neck, back and/or muscular pain have confirmed that Botox®/Dysport® treatments often reduce the frequency and intensity of such pain. Patients who respond well to Botox®/Dysport® generally experience improvement within a few days, sometimes enjoy several months of at least partial relief from such pain, and are able to greatly reduce (and in some cases eliminate) pain medications.


    Botox®/Dysport® can be very cost effective when it reduces consumption of medications, and allows patients to avoid missing work. An increasing duration of effect is often noted in chronic pain patients who repeat their Botox®/Dysport® treatments as soon as they notice that the Botox®/Dysport® effect is declining.


    In some cases, trigger points can be identified as being associated with your neck, back and/or muscular pain and these would be ideal for injection with Botox®/Dysport®, usually starting at 5 to 25 units of Botox®/Dysport® in each point. In other cases, it is more effective to treat larger areas with a total of 75-600 units of Botox®/Dysport®. Dr. Waldron would be happy to discuss with you, in detail, the treatment of chronic neck, back and/or muscular pain.

  • Botox®/ Dysport® for Headaches

    When Botox®/Dysport® are used to treat headaches the cost of the medication and treatment may be partially reimbursable. Check with your third party health insurance, (i.e. Blue Cross, employee health plans etc.), to find out if you are covered.


    A number of patients treated with Botox®/Dysport® for lines on the forehead, frown lines between the eyebrows, and for crow’s feet have reported that a pleasant side effect of Botox®/Dysport® treatment was reduction or elimination of headaches.


    Formal studies of patients with headaches have confirmed that Botox®/Dysport® treatment often reduces the frequency and intensity of both muscle tension headaches and also some migraine headaches. Patients who respond well to Botox®/Dysport® generally experience improvement within a few days, sometimes enjoy several months of relief from headaches, and are able to greatly reduce (and in some cases eliminate) headache medications. Botox®/Dysport® can be very cost effective when it reduces consumption of medications, and allows patients to avoid missing work. An increasing duration of effect is often noted in headache patients who repeat their Botox®/Dysport® treatments as soon as they notice that the Botox®/Dysport® effect is declining.


    In some cases, each point which you can identify as being associated with your headaches will be injected with Botox®/Dysport®, usually starting at 5 to 25 units of Botox®/Dysport® in each point. In other cases, it is more effective to treat larger areas (for example, the forehead and sides of the scalp) with a total of 75-600 units of Botox®/Dysport®. Dr. Waldron would be happy to discuss with you, in detail, the treatment of headaches.

  • Botox®/Dysport® for Excessive Sweating

    When Botox®/Dysport® is used to treat excessive sweating the cost of the medication and treatment may be partially reimbursable. Check with your third party health insurance, (ie Blue Cross, employee health plans etc.), to find out if you are covered.


    Botox®/Dysport® is also used to control excessive sweating of the armpits and palms, and occasionally other parts of the body. About one person in 100 has a serious problem with excessive sweating in these areas. This usually starts in childhood or adolescence, and sometimes other family members have a similar problem. This kind of excess sweating is caused by a reflex reaction of the nervous system and is beyond voluntary control. This kind of excessive sweating is sometimes associated with stress or heat, but often there is no cause that can be identified.


    There can be considerable emotional and social stigma attached to excessive sweating of the hands and armpits, and this can lead to a loss of confidence and self-esteem. For example, those afflicted with excessive sweating often feel that when people see big sweat marks under their arms or feel their sweaty palms they may decide that the individual is nervous or insincere, even when that is not the case. Social engagements and simple things like physical contact with other people may be avoided because of uncontrollable sweating.


    Patients afflicted with excessive sweating can routinely soak through clothing in a matter of minutes, and some patients have to use Kotex™ pads in their armpits, shields, absorbent tissues and frequent changes of clothing to cope with the disorder. Shirts and jackets can be quickly stained and ruined, and dry cleaning and replacement of clothing is sometimes a substantial expense.


    Questions to ask yourself when considering Botox®/Dysport® treatment for excessive sweating include:

    • Over the past week, how embarrassed or self-conscious have you been because of your sweating?
    • Over the past week, how much has your sweating interfered with normal activities like shopping or looking after your home?
    • Over the past week, how much has your sweating influenced the clothes you wear?
    • Over the past week, how much has sweating affected any social or leisure activities?
    • Over the past week, how much has sweating made it difficult for you to enjoy any sport?
    • Over the past week, has your sweating interfered with working or studying?
    • •Over the past week, has your sweating created problems with your partner, friends or relatives?
    • Over the past week, how much has your sweating created sexual difficulties or interfered with intimacy?

    Individuals troubled by excessive sweating often do not respond adequately to antiperspirants, and they may not respond to (or be willing to tolerate) systemic medications, electrical treatments on the areas of excessive sweating, permanent destruction of the nerves which control sweating, or surgery (in the armpits) to either scrape away the sweat glands or to cut out the areas of excessive sweating.


    Botox®/Dysport® treatment, by contrast with the above, is a simple office procedure with little discomfort or risk; and can be much less expensive than surgery. Some people will only want Botox®/Dysport® treatment before an important event (for example, a wedding). Others, whose sweating is mainly a problem during hot weather, may have Botox®/Dysport® treatment at the start of every summer. Botox®/Dysport® treatments can be safely continued year-round if necessary to maintain control of your sweating.

    Treatment of the armpits is easy, and no anesthetic is needed. Both armpits can be treated at the same time. After Botox®/Dysport® treatment, excess sweating starts to decrease within a couple of days, and the full effect is reached in a week or two. The goal of Botox®/Dysport® is reduction of sweating to a normal level, but not total elimination of sweating to the point where the treated area becomes abnormally dry.


    The effect of the Botox®/Dysport® treatment for excessive sweating usually lasts for 4-6 months, but in some cases can last for up to a year. Because you continue to sweat normally in other areas, there is no concern about overheating.


    Patients usually report very high satisfaction with Botox®/Dysport® treatments, return for additional treatments, and would recommend Botox®/Dysport® treatments to their friends. Dr. Waldron would be happy to discuss with you, in detail, the treatment of excessive sweating.