Botox Consent
Name
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First Name
Last Name
What is being injected? Botulinum Toxin (may be branded Xeomin, Botox or Bocouture) is a purified protein produced by the bacterium ‘clostridium botulinum’. The product causes muscle relaxation and suppresses sweating for 2-6 months on average (with wide variation between individuals) by temporarily disrupting nerve activity to muscles and sweat glands. I understand that often treatments are given ‘off label’ because licensed use of prescribed treatments do not include most areas of available treatment. Please initial that you have thoroughly read and understand:
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Limitations and alternatives: Occasionally the treatment wears off very quickly or does not work at all. Botulinum Toxin is best at treating dynamic facial lines (which are those caused by facial muscle activity). Lines which are present when the face is ‘at rest’ may or may not improve and results can be unpredictable. Alternatives: I have considered alternatives to treatment, including doing nothing, topical creams, chemical peels, laser treatments, surgical denervation, forehead/brow lift, facelift, or hyaluronic acid treatments and elected that at this time Botulinum toxin is the best option for me. Follow-up: I understand that free enhancement injections are only available for up to 4 weeks after my initial treatment, and thereafter will be treated as a new treatment at full price. I agree to follow the aftercare advice provided in full. Dissatisfaction: I understand that with all treatments the actual degree of improvement cannot be predicted or guaranteed. The outcome’s subjective nature means dissatisfaction is a possible outcome regardless of the effectiveness of treatment. I understand that the effect of all treatments will gradually wear off and additional treatments will be necessary to maintain the desired effect. No refund policy: I understand that results cannot be guaranteed and that the treatment of side effects and complications is included in the cost of the procedure and therefore no refunds can be given due to any of the above occurring. Please initial you have thoroughly read and understand:
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Agreement: By signing this form, I agree that I have considered the side effects, risks and uncertainty of the outcome and decided the treatment is still in my best interests at this moment in my life. I have discussed all the details important to me with my clinician and shared all the information my clinician may need to plan a treatment. I agree that the balance of the benefits and risks to me overall, favors the use of botulinum toxin. I accept all the risks, complications and conditions of the procedure. I understand photographs are taken and stored as part of my clinical record. Please initial you have thoroughly read and understand:
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Have you had dermal filler treatment or botulinum toxin?
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Yes
No
Have you had any previous facial surgeries?
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Yes
No
Facial cold sores?
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Yes
No
Are you pregnant or breast feeding?
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Yes
No
Do you suffer from Myasthenia Gravis, Eaton Lambert Syndrome or Bell's/Facial Palsy?
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Yes
No
History of severe allergy/anaphylaxis to BOTOX or its exipients?
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Yes
No
Do you have a life event in the next 2 weeks? (Wedding, family pictures, etc.)
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Yes
No
Our insurance company requires "Before and After" photos/ videos kept on file. We would like your permission to use these photos/videos for advertising: for example, in portfolios, online and in print ads, etc. If you would like your photos/videos used or not used in advertising, please type the following in the text box provided: YES, feel free to use them YES, but only procedure area please. NO, Please do not use them. If you do not mark anything, we will assume you are okay with sharing your images.
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Yes, feel free to use them
Yes, but only the procedure area please
No, please do not use them
Please sign verifying all information provided has been reviewed by the patient receiving Botox.
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Submit
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