Botox Cosmetic Consent

I am aware that when a small amount of neuro modulation (Botox/Dysport) 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, corrugated beneath the inner part of each eyebrow. Injecting Botox or Dysport into this muscle will relax it causing improvement or disappearance of the active lines. This appears in 7-10 days and usually last 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

Botox treatment of frown lines can cause minot temporary droop of one eyelid in approximately 5-10 days of injections. This usually lasts 2-3 weeks, but it can last longer. Redness, swelling, and tenderness can happen at the site of injection, which usually lasts 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 situations 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 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.