This consent form confirms that I have been fully informed and educated regarding Kenalog® (triamcinolone acetonide) injections, including their purpose, mechanism of action, expected benefits, alternatives, limitations, risks, and possible complications. I acknowledge that I have received adequate information to make a voluntary and informed decision to proceed with treatment.

Indication for Treatment

I understand that Kenalog® injections may be administered for conditions discussed with my provider, including but not limited to keloids, hypertrophic scars, inflammatory acne lesions, or other inflammatory or proliferative skin conditions.

Nature of the Product

• I understand that Kenalog® (triamcinolone acetonide) is a corticosteroid medication that works by reducing inflammation, immune response, and abnormal tissue activity.
• I understand that when administered intralesionally or intradermally, Kenalog® is intended for localized treatment and is not used as systemic steroid therapy.

Procedure Description

• I understand that the procedure involves using a thin needle to inject Kenalog® directly into the affected area.
• I understand that improvement may occur after the first treatment; however, multiple treatment sessions may be required depending on the condition, severity, and individual response.

Expected Results & No Guarantee

• I understand that although favorable outcomes are expected, medicine is not an exact science and no specific result or degree of improvement can be guaranteed, either expressed or implied.
• I understand that I am paying for professional medical services, not for a guaranteed outcome.

Alternatives to Treatment

• I understand that alternatives may include observation, topical medications, oral medications, laser or device-based treatments, surgical intervention, or no treatment.
• I confirm that these alternatives have been discussed with my provider and that I have had the opportunity to ask questions.

Medical Disclosure & Contraindications

• I agree to fully disclose all medical conditions, allergies, and medications, including supplements.
• To the best of my knowledge, I have no known allergies or sensitivities to Kenalog®, triamcinolone acetonide, or corticosteroids.
• I deny a history of idiopathic thrombocytopenic purpura (ITP).
• I deny that I am currently pregnant, attempting to become pregnant, or breastfeeding. I understand that the safety of Kenalog® during pregnancy and breastfeeding has not been established, and animal studies suggest potential fetal risk. If uncertain, I will request pregnancy testing prior to treatment.

Risks & Possible Complications

I understand that all injectable procedures carry risk. Potential risks associated with Kenalog® injections include, but are not limited to:

• Discomfort or pain at the injection site
• Bleeding or bruising
• Infection (rare)
• Scarring (rare)
• Allergic reactions
• Delayed healing
• Skin lightening (hypopigmentation)
• Telangiectasia (small visible blood vessels)
• Soft tissue atrophy
• Unknown or unforeseen side effects

Soft Tissue Atrophy Disclosure

• I understand that soft tissue atrophy, or thinning of the skin or underlying tissue, is a known risk of steroid injections.
• I understand that this may present as dimpling or indentation at the injection site.
• I understand that small areas of atrophy may improve over weeks to months, while larger or persistent areas may require additional treatment, such as fillers or laser therapy, at my own expense.

Vaccination Disclosure

• I understand that live vaccines should not be administered while being treated with Kenalog®, as steroid therapy may reduce vaccine effectiveness and immune response.

Patient Variability & Delayed Reactions

I understand that individual responses vary and that delayed reactions may occur. I agree to promptly notify AI Wellness Center of Excellence if I experience any unusual, worsening, or concerning symptoms.

Procedure Explanation & Post-Care

• I understand that the procedure, including its benefits, risks, alternatives, and post-treatment care, has been explained to me.
• I agree to follow all pre- and post-treatment instructions provided by my provider.

Authorization & Provider Qualifications

• I hereby authorize Dr. Gideon Kwok, D.O., and/or trained and qualified licensed medical providers acting within their scope of practice to perform Kenalog® (triamcinolone acetonide) injections.
• I acknowledge that I have had the opportunity to inquire about the qualifications and experience of the provider administering my treatment and that I am satisfied.
• I affirm that my consent is voluntary, informed, and freely given.

Final Acknowledgment

I acknowledge that I have read and fully understand this consent form, that all disclosures have been explained to me, that I have had the opportunity to ask questions, and that this form supersedes any prior verbal or written disclosures. I freely consent to Kenalog® (triamcinolone acetonide) injections.