BOTOX/ DYSPORT CONSENT FORM
Botox relaxes the muscles of the face that cause wrinkles associated with facial expressions. Treatment can smooth these expression lines. Areas most frequently treated are: the glabellar area (located between the eyes); crow’s feet (lateral areas of the eyes); forehead wrinkles. Botox and Dysport are diluted to precise concentrations and injected into the muscles with a very thin needle. There is minimal discomfort. Clients may feel a slight stinging sensation as the solution is being injected. The procedure takes about 15-30 minutes and the results can last 3-5 months. With repeated treatments, the results tend to last longer.
Risks and complications
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, swelling, redness, and bruising. 4) Occasional numbness of the forehead lasting up to 2-3 weeks
- Post treatment bacterial, viral and/fungal infection. 5) Minor temporary drooping of eyelids.
- Allergic reaction, transient headache or flu-like symptoms.
Is there anyone who should not have this procedure?
Tell your doctor about all your medical conditions, including but not limited to:
*A disease that affects muscles and nerves: ALS, Lou Gehrig’s disease, myasthenia gravis, or Lambert-Eaton syndrome including prior stroke.
*Are pregnant or plan to become pregnant. It is known that Botox or Dysport can harm your unborn baby.
*Are breast-feeding or plan to breastfeed. It is known that Botox or Dysport passes into breast milk.
*Allergies to any botulinum toxin product. *A breathing problem. *Bleeding problems
*Had surgery on your face *Drooping eyelids *Swallowing problems *Plans to have surgery
*Weakness of your forehead muscles, such as trouble raising your eyebrows. *Any other change on the way your face normally looks.
Tell your doctor about all the medicines you take, including prescription and nonprescription medicines, vitamins and herbal products. Using BOTOX or DYSPORT with certain other medicines may cause serious side effects. Do not start any new medicines until you have told your doctor that you have received BOTOX or DYSPORT in the past. Please inform your doctor especially if you:
- Have received any other botulinum toxin in the last 4 months. These include: Myobloc (rimabotulinumtoxinB), Dysport (abobotulinumtoxinA), or Xeomin (incobotulinumtoxinA). Make sure your doctor knows exactly which product you received.
- Have recently received an antibiotic by injection.
- Take an allergy or cold medicine, muscle relaxants or sleep medicine.
I authorize the taking of clinical photographs for my medical record only and will not be shared in any way without my written consent.
Results are typically seen in 3-10 days and usually lasts 3-5 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. Retreatment may be necessary if asymmetry develops. There results will gradually decrease over a period of months at which time retreatment is appropriate.
CONSENT TO BOTULINUM TOXIN “A” TREATMENT
I hereby voluntarily consent to treatment with BOTOX or DYSPORT injected for the condition known as: Facial Dynamic Wrinkles.
- I have read the above.
- The procedure has been explained to me.
- My questions have been answered satisfactorily.
- I accept the risks and complications of the procedure.