Neurotoxin Consent

PURPOSE

The purpose of this form is to provide written information regarding the risks, benefits and alternatives of the administration of BOTULINUM TOXIN A (Botox or Dysport), to be referred to as "Botox". Botox is used in the correction of mild to moderate facial lines, wrinkles, muscle tension and headaches related to muscular movement. All medical and cosmetic procedures carry risks and may cause complications. The purpose of this document is to make you aware of the nature of the procedure and its risks in advance so that you can decide whether to proceed with the procedure. This material serves as a supplement to the discussion you have with your doctor/healthcare provider. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing the consent form.

PROCEDURE

Neurotoxins or Neuromuscular Blockers (i.e. Botox or Dysport) can relax the muscles of the face and neck which cause wrinkles associated with facial expressions or facial pain. Whether for cosmetic or therapeutic treatment, Neurotoxins can cause your facial expression lines or wrinkles to be less noticeable or essentially disappear. The most frequently treated areas are:

1. Glabella (frown lines located between the eyes)
2. Crow's Feet (lateral areas of the eyes) 
3. Forehead wrinkles 
4. Radial Lip Lines (smoker's lines) 
5. Head, neck and jaw muscles

Neurotoxins are 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 can last up to 3 months. With repeated treatments, the results may tend to last longer.

No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list.

• Post treatment discomfort, swelling, redness, and bruising. Most people have lightly swollen pinkish bumps at the injection site for a few hours or even several days.
• Minor ptosis (drooping) of the eyebrow or eyelid; occurs in approximately 2% of injections, this usually lasts 2-3 weeks. While local weakness of the injected muscles is representative of the expected pharmacological action of Neurotoxins, weakness of adjacent muscles may occur as a result of the spread of the toxin.
• In some cases, ptosis may lead to the inability to blink, double vision, weakened tear duct, and corneal exposure.
• Post treatment bacterial, and/or fungal infection requiring further treatment.
• Symptoms of an allergic reaction: itching, rash, red itchy welts, wheezing or asthma symptoms, dizziness or feeling faint. Seek immediate medical help if you experience wheezing or feel faint/dizzy.
• Occasional numbness of the forehead lasting up to 2-3 weeks.
• Transient headache.
• Flu-like symptoms may occur.

• Do NOT undergo injections if you are allergic to or have had an allergic reaction to any ingredients found within Botox, Dysport, Myoblock, or Zeomin.
• Do NOT have cosmetic injection of Neuromuscular products if you are getting any of these products injected elsewhere in your body for ANY reason.
• Use during pregnancy or breastfeeding is NOT recommended.
• Infection at the proposed injection site.
• Pre-existing Neuromuscular Disorders such as ALS (Lou Gehrig's Disease), Myasthenia Gravis, or Eaton- Lambert Syndrome.
• Are being treated for Cervical Dystonia, Dysphagia, or breathing difficulties.

MY SIGNATURE BELOW INDICATES THAT:

• I have read the above and understand it.
• The procedure has been fully explained to me and I have been given sufficient opportunity for discussion of all of my questions.
• I confirm that I am not pregnant, breastfeeding, or have any significant neurological disease as noted above.
• I consent to the taking of photographs/videos and authorize their use for the purpose of medical audits, education, and social media.
• I understand that this is strictly a cosmetic procedure and individual results may vary. I have been given no guarantees as to the outcome, and I understand that the results are temporary and several sessions may be needed to achieve/maintain optimal results. All additional treatments are at additional cost.
• My signature constitutes my consent for treatment with neurotoxin, and I understand that neurotoxins can have serious side effects including the spread of toxin effects which can include problems breathing or swallowing which can be life threatening. This can happen hours, days or weeks after injection.
• My signature also acknowledges that I have received and read a copy of Pre-Care and Post-care instructions.

I certify that I have explained the nature, purpose, benefits, risks, complications and alternatives of the proposed procedure to the patient. I have answered fully, and I believe that the client fully understands what I have explained.