KEC Cosmetic Botox_Xeomin Consent

Botox and Xeomin is a brand name for botulinum toxin-type A, a neurotoxin that blocks messages between muscles and nerves that control them.

The FDA has approved the use of Botox and Xeomin to treat facial dystonias (spasms), strabismus (crossed eyes), and to temporarily soften facial rhytids (wrinkles) between the eyebrows and crows feet. While the FDA has not approved injections to improve the appearance of wrinkles in other areas of the face, physicians may perform these “off label” procedures.

The temporary effects of Botox/Xeomin become apparent 2-5 days after the injection is given and generally last 4-6 months. There are alternatives to Botox/Xeomin which include medications, surgery on facial nerves and muscles or no treatment.

Side Effects and Complications include but are not limited to:

Bruising
Under-correction (not enough effect) or overcorrection (too much effect)
Facial asymmetry (one side looks different than the other)
Droopy eyelid, double vision, inability to close eye, drinking from a straw
Generalized weakness
Permanent loss of muscle tone with repeated injection
Flu-like symptoms or respiratory infection, nausea or headaches
Development of antibodies
Derived albumin and carries a theoretic risk of virus transmission.
There have been no reports of disease transmission.

Contraindications:

You should not have Botox/Xeomin if you are allergic to albumin, pregnant, nursing, have an infection, or have Eaton-Lambert Syndrome, Lou Gehrig’s disease, or myasthenia gravis. No guarantees regarding results have been made.

The potential benefits have been explained of Botox/Xeoming along with alternative methods.

Please read & initial *

	Patient's Initials
I understand that Botox/Xeomin is an elective procedure, that insurance does not cover this procedure and that I am solely responsible for payment. Fee structure and payment have been fully explained to me. (Botox $12 per unit, Xeomin $11 per unit) I understand that the amount due depends on the amount of units Dr. Nancy Chen uses.
Discounted or special priced treatments must be prepaid in full by first treatment appointment. Incomplete and/or cancelled treatments will be charged at regular/full price, NO refunds.
I understand that necessary photos will be taken before, during and after the course of my treatments for medical purposes and to evaluate treatment effectiveness. I understand that my photos will be kept confidential in my electronic patient record.
I consent to photographs and other audio-visual and graphic materials before, during and after the course of my treatments to be used for marketing and medical educational purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I may or may not be identified by the photos.

I have read and understand all information presented to me before signing this consent form. I have been given an opportunity to have all of my questions answered to my satisfaction. I understand the procedure and accept the risks. I authorize Dr. Chen to administer Botox/Xeomin injections today and for future treatments as needed.

I assume all risks as my own and agree to hold harmless, Kapolei Eye Care; their providers, estheticians, and any other staff member, affiliate, or independent contractor. I hereby release them from any liability, both seen and unforeseen, now and forever.

Patient's Signature

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Patient's Name *

First Name Last Name

Patient's Date of Birth *

Patient ID#

Date

Witness Signature

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Witness Name

First Name Last Name

Physician's Signature: Nancy Chen, M.D.

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