You have the right and obligation to make decisions concerning your health care. Your doctor can provide you with the necessary information and advice, but because this affects you, you must enter into the decision making process.
This form has been designed to acknowledge your acceptance of treatment recommended by your doctor. Please feel free to ask any questions.
1. I hereby authorize NANCY CHEN, M.D. (and any associate or assistant involved in my care) to treat the following condition(s) which has (have) been explained to me:
Ordinary or Lay Language: DOUBLE VISION
2. The procedure(s) planned for treatment of my condition(s) has (have) been explained to me by my doctor as follows:
Professional: BOTOX INJECTIONS TO THE AFFECTED AREA(S)
Ordinary or Lay Language: INJECTIONS OF BOTOX TO THE AFFECTED AREA(S)
3. I have been informed that there are many minor risks involved during the procedure such as:
under-correction (not enough effect) or overcorrection (too much effect)
decrease in vision
permanent loss of muscle tone with repeated injection
flu-like symptoms or respiratory infection
nausea or headaches
development of antibodies
Botox/Dysport contain human-derived albumin and carries a theoretic risk of virus transmission. There have been no reports of disease transmission.
4. I have been informed that there are my significant risks, such as severe blood loss, infection, cardiac arrest, and other consequences that can lead to death or permanent or partial disability, which can result from any procedure.
5. No promise or guarantee has been made to me as to result or cure.
6. I consent to the administration of (general, regional, or local) anesthesia by and anesthesiologist, by my attending physician, or by other qualified individual under the direction of a physician as may be deemed necessary. I understand that all anesthetics involve risks that may result in complications and possible serious damage to such vital organs as the brain, heart, lungs, liver and kidney. These complications may result in paralysis, cardiac arrest and related consequences or death from both known and unknown causes.
7. I consent to the photographing, videotaping, televising or other audio and/or visual recording of this operation, post-operative care, medical treatment, anesthesia, or other procedures for medical or scientific purposes or for the
purpose of advancing medical education, provided my identity is not revealed by the pictures, by the recording or by the descriptive texts accompanying them.
8. Also, for the purpose of advancing medical education, I consent to the admittance of observers to the operating room, during my post-operative care, medical treatment, anesthesia or other procedure(s).
9. I have had the opportunity to ask questions about this form.
I AGREE THAT MY PHYSICIAN HAS INFORMED ME OF THE:
Diagnosis or probable diagnosis
Nature of the treatment or procedure(s) recommended
Risks or complications involved in such treatment or procedure(s)
Alternative forms of treatment, including non-treatment available
Anticipated results of the treatment