Botox Medical History

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CONSENT TO BOTOX BOTULINUM TOXIN “A” TREATMENT

Botox is a neurotoxin produced by the bacterium Clostridium A. Botox can relax the muscles on areas of the face and neck which cause wrinkles associated with facial expressions. Treatment with Botox can cause your facial expression lines or wrinkles to essentially disappear. Areas most frequently treated are: glabellar area of frown lines, located in between the eyes; crow’s feet; and forehead wrinkles. Botox is diluted to a very controlled solution and when injected into the muscles with a very thin needle, it’s almost painless. Clients might feel a slight burning sensation while the solution is being injected. The procedure takes about 15-20 minutes and the results last 3-6 months. With repeated treatments, the results may tend to last longer.

RISKS & COMPLICATIONS:

It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure and in this specific instance such risks include but are not limited to: Post treatment discomfort- i.e. swelling, redness, bruising; Double vision; Rarely weakened tear duct; Post treatment bacterial, and/or fungal infection requiring further treatment; Allergic reaction; Minor temporary droop of eyelid(s) in approximately 2% of injections, that usually last 2-3 weeks; Transient headache; Flu-like symptoms may occur

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, ALLERGIES, & NEUROLOGICAL DISEASE:

I am not aware that I am pregnant, I am not trying to get pregnant, and I am not lactating (nursing), have any significant neurologic disease including but not limited to Myasthenia Gravis, Multiple Sclerosis, Lambert-Eaton Syndrome, Amyotrophic Lateral Sclerosis (ALS), Parkinsons, or that I have any allergies to the toxin ingredients, or to human albumin.

PAYMENT:

I understand that this is an “elective” cosmetic procedure and that payment is my responsibility

RESULTS:

I am aware that when small amounts of purified botulinum (BOTOX) are injected into a muscle, it causes weakness or paralysis of that muscle. This appears in 2-10 days and usually lasts 3-6 months but can be shorter or longer. In a very small amount of individuals, the injections do not work as satisfactorily, or for as long as usual. There are some individuals that do not respond at all. I understand that I will not be able to “frown” while the injection is effective but that this will reverse after a period of months at which time re-treatment is appropriate. I understand that I must stay in the upright posture and that I must not manipulate the area(s) of the injections for the 2 hours post-injection period. I understand that this is an elective procedure and I hereby voluntarily consent to treatment with BOTOX injection for the condition known as: Facial Dynamic Wrinkles. The procedure has been fully explained to me. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure and I understand that no guarantees are implied as to the outcome of the procedure. I also certify that if I have any changes in my medical history I will notify the office immediately.

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