CONSENT TO BOTULINUM TOXIN “A” (BoNT-A) TREATMENTg
I understand that I will be injected with a brand of Botulinum A Toxin (Botox®/Dysport®/ Xeomin®/ Jeuveau®) to manage Facial Dymanic Wrinkles and/ or Hyperactive Muscles.
Botox®, Dysport, Xeomin & Jeuveau are 4 brands of a neurotoxin produced by the bacterium Clostridium A. that can relax the muscles on areas of the face and neck that cause wrinkles associated with facial expressions. Treatment with BoNT-A can cause your facial expression lines or wrinkles to diminish and can relax hyperactive muscles that may contribute to facial pain and discomfort. Areas most frequently treated are: a) glabellar area of frown lines, located between the eyes; b) crow’s feet (lateral areas of the eyes); and c) forehead wrinkles. Other areas considered Off-label may also be treated, which I consent to by signing this document below.
BoNT-A is diluted to a very controlled solution and when injected into the muscles with a very thin needle, it is almost painless. Patients may feel a slight burning sensation while the solution is being injected. The procedure takes about 15-20 minutes and the results last 3-4 months. With repeated treatments and correct number of units, the results may tend to last longer.
RISKS AND 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 : 1) Post treatment discomfort, swelling, redness, and bruising, 2) Post treatment bacterial, viral, and/or fungal infection requiring further treatment, 3) Allergic reaction, 4) Minor temporary drop of eyelid(s) in approximately <1% of injections, this usually lasts 2-3 weeks, 5) Occasional numbness of the forehead lasting up to 2-3 weeks, 6) Transient headache, and 7) Flu-like symptoms may occur.
PREGNANCY, ALLERGIES & NEUROLOGIC DISEASE
I am not aware that I am pregnant, have any significant Neurologic disease, or have any allergies to the toxin ingredients, or to human albumin.
RESULTS
I am aware that when small amounts of purified botulinum (“BOTOX®”, DYSPORT, XEOMIN or JEUVEAU) are injected into a muscle it causes weakness or relaxation of that muscle. This result appears in 3-7 days and usually lasts 3-4 months but can be shorter or longer. In a very small number of individuals, the injection does not work as satisfactorily or for as long as usual. I understand that I will not be able to move the treated muscles 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 erect posture and that I must not manipulate the area of the injection for the four hours post-injection period.
I consent that payment is due in full at the time of service and that there are no refunds under any circumstances. I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment.
I hereby voluntarily consent to treatment with Botulinum Toxin Type A injection for the condition known as: Facial Dynamic Wrinkles and or Management of Hyperactive Muscles. The procedure has been 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 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 injector immediately. By signing below, I hereby release the doctor, the person injecting the Botulinum Toxin- A and the facility from liability associated with this procedure.