Before considering treatment with Botulinum Toxin A (BTA), I state that to the best of my knowledge I do NOT have any of these conditions:

• Disease that affects muscles and nerves (ALS or Lou Gehrig's disease, Myasthenia Gravis, or Lambert-Eaton syndrome.)
• Allergies to any botulinum toxin product 
• Allergies to cow's milk products (Dysport only) 
• Allergies to human serum albumin products (Xeomin only)
• Any past side effects from BTA (Botox, Dysport, Xeomin, MyoBlock) 
• Serious breathing problems, such as asthma or emphysema 
• Swallowing problems or aspiration (inhaling food or fluid into your lungs) 
• Pregnancy or active breastfeeding

INSTRUCTIONS

Beingfully informed about your condition and treatment will help you decide whether to undergo treatment with botulinum type A (BTA This disclosure is not meant to alarm you; it is simply an effort to better inform you so that you may give or withhold your consent for this It treatment.is important that you read this information carefully and completely. Please sign the consent for this procedure proposed by your healthcare provider.

INTRODUCTION

Clostridium botulinum bacteria produce a class of chemical compounds known as "toxins." The BTA is processed and purified to produce a sterileproduct suitable for specific therapeutic use. Once the diluted toxin is injected, it produces a temporary paralysis (chemodenervation) ofby preventing the transmission of nerve impulses to the muscle. The duration of muscle paralysis generally lasts for approximately muscle three months.BTA has been used to treat certain conditions involving crossed eyes (strabismus), eyelid spasm (blepharospasm), and motor disorders of the facial nerve (VII cranial nerve It has been used in other "off-label uses for the treatment of facial wrinkles and neck bands caused by specific muscle groups. Certain spastic muscle disorders with the neck and colorectal area have also been treated with this agent. BTA injections are customized for every patient, depending on his or her particular needs. These can be performed in areas involving the eyelid region, forehead, and neck. BTA cannot stop the process of aging. It can, however, temporarily diminish the look of wrinkles caused by muscle groups.

ALTERNATIVE TREATMENTS

Alternative forms of management including not treating the skin wrinkles by any means. Improvement of the skin wrinkles may be accomplished by other treatments or alternative types of surgery such as a blepharoplasty, face or brow lift when indicated. Other forms of eyelid surgery may be needed should you have intrinsic disorders affecting the function of the eyelid, such as drooping eyelids from muscle problems (eyelid ptosis) or looseness between the eyelid and eyeball (ectropion Minor skin wrinkling may be improved throughchemical skinpeels, lasers, injection of filling material, or skin treatments. Risks and potential complications are associated with alternative forms of medical or surgical treatment.

RISK OF BOTULINUM TOXIN A INJECTIONS

Every procedure involves a certain amount of risk, and it is important that you understand the risks involved. An individual's choice to thisprocedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience the undergo following complications, you should discuss each of them with your provider to make sure you understand the risks, potential complications, and consequences of BTA injections.

BLEEDING

It is possible,though unusual, to have a bleeding episode from a BTA injection. Bruising in soft tissues may occur. Serious bleeding around theeyeball during deeper BTA injections for crossed eyes (strabismus) has occurred. Should you develop post-injection bleeding, it may require emergency treatment or surgery. Doaspirin or anti-inflammatory medications for two days before BTA injections, as this may contribute to a greater risk of a nottake bleeding problem.

DAMAGE TO DEEPER STRUCTURES  

structures such as nerves, blood vessels, and the eyeball may be damaged during the course of injection. Injury to deep structures may Deeper be temporary or permanent.

CORNEAL EXPOSURE PROBLEM

Some patients experience difficulties closing their eyelids after BTA injections, and problems may occur in the cornea due to dryness. Should this rare complication occur, additional treatments, protective eye drops, contact lenses, or surgery may be necessary.

DRY EYE PROBLEMS

Individuals who normally have dry eyes may be advised to use special caution in considering BTA injections around the eyelid region.

MIGRATION OF BTA

BTA may migrate from its original injection site to other areas and produce temporary paralysis of other muscle groups and other unintended effects.

DROOPING EYELIDS (PTOSIS)

Muscles that raise the eyelid may be affected by BTA should this material migrate downward from other injection areas.

DOUBLE VISION

Double vision may be produced if the BTA material migrates into the region of muscles that control the movement of the eyeball.

EYELID ECTROPION

Abnormal looseness of the lower eyelid can occur following BTA injection.

OTHER EYE DISORDERS

Functional and irritative disorders of eye structures may rarely occur following BTA injections.

ASYMMENTRY

The human face and eyelid region are normally asymmetrical with respect to structural anatomy and function. There can be a variation from one side to the other in terms of the response to BTA injection.

PAIN

Discomfort associated with BTA injections is usually short duration.

SKIN DISORDERS

Skin rash and swelling may rarely occur following BTA injection.

UNKNOWN RISKS

The long-term effects of BTA on tissue are unknown. There is the possibility of additional risk factors may be discovered.

UNSATISFACTORY RESULTS 

There is the possibility of a poor or inadequate response from BTA injection. Additional BTA injections may be necessary. Surgical procedures or treatments may be needed to improve skin wrinkles, including those caused by muscle activity.

ALLERGIC REACTIONS

As with all biological products, allergic and systemic anaphylactic reactions may occur. Allergic reactions may require additional treatment.

ANTIBODIES TO BTA

The presence of antibodies to BTA may reduce the effectiveness of this material in subsequent injections. The health significance of antibodies to BTA is unknown.

INFECTION

The infection is extremely rare after BTA injection. Should an infection occur, additional treatment, including antibiotics, may be necessary.

LONG-TERM EFFECTS

Subsequent alterations in the face and eyelid appearance may occur as a result of aging, weight loss or gain, sun exposure, or other circumstances not related to BTA injections. BTA injection does not arrest the aging process or produce permanent tightening of the eyelid region. Future surgery or other treatments may be necessary.

PREGNANCY AND NURSING MOTHERS

Animalreproduction studies have not been performed to determine if BTA could produce fetal harm. It is not known if BTA can be excreted in human milk.

BLINDNESS

Blindness is extremely rare after the BTA injections. However, it can be caused by internal bleeding around the eyeball or needle stick injury. The occurrence of this is very rare.

DRUG INTERACTIONS

The effort of BTA may be potentiated by aminoglycoside antibiotics or other drugs to interfere with neuromuscular transmission.

NON-FDA APPROVED USERS

We only use FDA-approved products purchased directly from the manufacturer. However, the injection sites may be different than those approved by the FDA.

RESULTS

I understand that the amount (number of units) injected is an estimate of the amount of BTA required to paralyze the muscles in order to get rid of the desired result. I understand the results are of temporary nature, and more treatments will be needed to maintain improvement. I also understand that there is no guarantee of the results of any treatment. Furthermore, I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I further agree, in the event of non-payment, to bear the cost of collection. And/or Court cost and reasonable legal fees, should this be required.

ADDITIONAL TREATMENT NECESSARY

There are many variable conditions in addition to risk and potential complications that may influence the long-term results of BTA injections. Even though risks and complications occur infrequently, the risks cited are the ones that are particularly associated with BTA injections. Othercomplications and risks can occur but are even more uncommon. Should complications occur, additional surgery or other treatments be maynecessary. The practice of medicine and surgery is not an exact science. Although good results are expected, there is no guarantee or warranty expressed or implied on the results that may be obtained.

FINANCIAL RESPONSIBILITIES

The cost of injection may involve several charges. This includes the professional fee for the injections follow-up visits to monitor the effectiveness of the treatment in the costs of the material itself. It is unlikely that injections to treat cosmetic problems would be covered by your health insurance. Additional costs of medical treatment would be your responsibility should complications develop from

DISCLAIMER

Informed-consent documents are used to communicate information about the proposed surgical treatment of a disease or condition along with disclosure of risk and alternative forms of treatment(s The informed-consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances.

However this informed-consent document should not be considered all-inclusive in defining other methods of care and risk encountered. Your provider may provide you with additional or different information, which is based on all of the facts pertaining to your particular case and the state of medical knowledge.

Informed-consent documents are not intended to define or serve as the standard of medical care. Standards of medical care are determined on thebasis of all of the facts involved in an individual's case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve.

It is important that you carefully and fully read the information provided within these pages and have all your questions answered before signing the consent below.

By signing below, I AM SATISFIED WITH THE EXPLAINATION and I hereby give my voluntary consent to this procedure and release Jordan Stone, RN BSN and her business staff from liability associated with the procedure.