• Consent for Botox

    Fill the form below after keenly going through the instructions.

  • I have requested that Dr. Elijah and/or such assistants selected to perform the procedure attempt to improve my facial expression lines with Botox.

    This treatment involves injecting multiple sites of the facial muscles with minute amounts of botulinum toxin. This protein temporarily weakens the facial muscles to give the skin a smoother and more rested appearance. Although the results are usually dramatic, I have been informed that this practice is not an exact science and that no guarantees can be or have been made concerning expected results in my case.

    I understand that the benefits develop over 2-10 days and can last 6 weeks to 5 months based on individual variability. I also understand that a small percentage of people are minimally responsive to the treatment. In some cases, the "response" lessens with repeated treatments due to antibody formation against the toxin, but usually less Botox is required after continued treatments.

    Side effects and potential complications have been reviewed with me and can include slight swelling, bruising, eyelid or brow droopiness, asymmetry of the face, or skin rash. A transient headache or flu-like symptoms may occur. Rarely, an adjacent muscle may be weakened for several weeks after an injection. Temporary double vision is extremely rare, but has been reported. These effects, along with natural muscle activity, will recover over many weeks or months. I have been advised of the post-treatment instructions, and understand that these should be followed to minimize risk of complications. These include to avoid hard rubbing or touching of the injection sites, to refrain from vigorous exercise for 12 hours, to avoid hot tubs or steam showers and to periodically contract the muscles involved.

    I have also been advised that results may vary with different treatments, i.e. one treatment may be better that the next, but this does not mean it has not worked, rather that your muscle activity may vary from time to time.

    I acknowledge that I will be advised of the following, if they pertain to me:
    pregnancy or breast feeding
    skin diseases
    taking blood thinners
    cancer
    liver disease or cirrhosis
    all medications I am currently taking
    rheumatoid arthritis
    neuromuscular diseases


    I certify that I have read and fully understand the above the paragraphs, and that I have the sufficient opportunity for discussion and to ask questions.

  • Please check off all that apply:

  • Do you consent to take these photos?*
  • Do you consent to share these photos with in-office marketing?*
  • Do you consent to share these photos on our website and social media?*
  • Do you consent to this procedure?*
  • Do you consent to being on the RENEW email list?*
  • Do you consent to communication with RENEW via text messages?*

  •  By signing below, I verify that I have read and understand the above statements and agree to them.

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