Informed Consent for Local Anesthetic Use (Injectable & Topical)

This informed consent confirms that I have been satisfactorily informed and educated regarding the use of local anesthetics, including injectable and topical anesthetics, for comfort during medical and aesthetic procedures. I acknowledge that I have received sufficient information regarding the purpose, benefits, risks, alternatives, and limitations of anesthetic use to make a voluntary and informed decision.

Nature & Purpose of Local Anesthesia

• I understand that a local anesthetic is a medication used to temporarily reduce or eliminate sensation in a specific area of the body to improve comfort during procedures.
• I understand that local anesthesia may be administered by injection and/or topical application, such as a numbing cream or gel.

Medication Disclosure

• I understand that anesthetics used at AI Wellness Center of Excellence are medical medications and, despite being commonly used and generally safe, carry potential risks and side effects.

Potential Side Effects

• I understand that minor side effects may include skin irritation, redness, rash, or contact dermatitis.
• I understand that although local anesthetics have a wide safety margin, local anesthetic systemic toxicity (LAST) can occur, particularly if excessive amounts are absorbed.

Local Anesthetic Toxicity (Important)

• I understand that the risk of toxicity is related to the amount used, the surface area treated, the duration of exposure, and individual health factors.
• I understand the warning signs of local anesthetic toxicity, which may include dizziness or lightheadedness, blurred vision, tinnitus (ringing in the ears), slurred speech, restlessness, agitation, nervousness, paranoia, muscle twitching or tremors, and, in rare cases, seizures or loss of consciousness.
• I agree to immediately notify my provider if I experience any of these symptoms.

Topical Anesthetic Safety Instructions

• I understand and agree to use only the amount of topical anesthetic applied by or directed by clinic staff.
• I understand that I should not apply topical anesthetic to more than 20 percent of total body surface area in a single day.
• I understand that I should not cover treated areas with plastic wrap or occlusive dressings.
• I understand that topical anesthetic should not be left on the skin longer than 60 minutes unless otherwise directed by my provider.

Restricted Use Acknowledgment

• I understand that any compounded or clinic-specific anesthetic formulations used at AI Wellness Center of Excellence are for in-clinic use only and may not be taken home, shared, used outside of provider instructions, or transferred to another individual.

Timing & Effectiveness

• I understand that for optimal effect, topical anesthetics are typically applied 15–30 minutes prior to a procedure, although timing may vary depending on the procedure and formulation.

Alternatives & Voluntary Consent

• I understand that alternatives to anesthetic use include proceeding without anesthesia or using alternative comfort measures, and that these options have been discussed with my provider.
• I acknowledge that I have had the opportunity to perform independent research and ask questions regarding anesthetic use.

Medical History & Contraindications

• I agree to disclose all medical conditions, allergies, and medications, including supplements.
• I deny that I am currently pregnant, attempting to become pregnant, or breastfeeding. I understand that the safety of local anesthetic use during pregnancy and breastfeeding has not been fully established. If uncertain, I will request pregnancy testing prior to treatment.

Risks & Possible Complications

I understand that risks associated with local anesthetics may include, but are not limited to:

• Allergic reactions
• Bruising, swelling, or tenderness, particularly with injected anesthesia
• Increased bleeding or bruising if taking blood thinners or anti-inflammatory medications
• Temporary pigment changes
• Infection (rare)
• Scarring (rare, typically associated with injections)
• Unknown or unforeseen side effects

Patient Variability & Delayed Reactions

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

Procedure Explanation & Post-Care

• I understand that the use of local anesthesia has been explained to me, including its benefits, risks, alternatives, and limitations.
• I agree to follow all pre- and post-procedure instructions provided to me.

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 administer local anesthetic to me.
• I acknowledge that I have had the opportunity to inquire about the qualifications and experience of the provider administering anesthesia 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 consent supersedes any prior verbal or written disclosures. I freely consent to the use of local anesthetics.