Botox Consent Form

  • Neurotoxin Cosmetic Patient Consent    

    I am aware that when a small amount of a neuro modulation (Botox, Dysport, Xeomin) is injected into a muscle it causes weakness of that muscle. For example: Frown lines between the eyebrows are due to contraction of a small muscle, corrugator beneath the inner part of each eyebrow. Injecting neurotoxin into this muscle will relax it causing improvement or disappearance of the active lines. This appears in 7-10 and usually lasts four months but can be shorter or longer. 

    Results and Postoperative Care 

    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. 

    I understand that I must stay in the erect posture and that I must not manipulate the area of the injection site for the four hour post-injection period. 

    Risks and Complications 

    Neurotoxin treatment of frown lines can cause minor temporary drop of one eyelid in approximately 5-10 of injections. This usually lasts 2-3 weeks but it can last longer. redness,swelling ,tenderness can happen at the site of injection which usually last for a few days. Transient headache can happen after injection In a very small number of individuals, the injection does not work as satisfactorily or for as long as usual. temporary double or blurred vision can happen in rare situation and it can last for a few months. Risk of infection is very low with this treatment. 

    Photographs 

    I authorize the taking of clinical photographs and their use for scientific purposes both in the publications and presentations. I understand my identity will be protected. 

    Pregnancy and Neurologic Disease 

    I am not aware that I am pregnant nor that I have any significant neurologic disease. 

    Payment 

    I understand that this is a cosmetic procedure and that payment is my responsibility and is not refundable after the treatment is done. 

    BY SIGNING BELOW, I ACKNOWLEDGE AND CERTIFY THAT I HAVE READ AND UNDERSTAND THE "CONSENT, RELEASE AND INDEMNITY AGREEMENT" FOR THIS PROCEDURE, AND THAT I AM SIGNING IT VOLUNTARILY. 

    PLEASE SIGN YOUR FULL NAME BELOW IF YOU AGREE 

  • I have read and agree with all the above statements in this consent form.
  • Date Format: MM slash DD slash YYYY