Patient Consent Form

Patient Name*

Date*

To the patient: Being fully informed about your condition and treatment will help you make the decision whether or not to undergo BOTOX® Cosmetic treatment. 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 treatment.

I, First Name* Last Name* will attempt to improve the facial lines withBOTOX® Cosmetic. This is the Allergan Inc. trademark for Botulinum Toxin Type A. These injections have been used for more than a decade to improve spasm of the muscles around the eye, to correct double vision due to muscle imbalance as well as numerous other neurological uses. BOTOX® Cosmetic is now approved by the FDA to improve the appearance of the vertical lines between the brows. A few tiny injections of BOTOX® Cosmetic relax overactive muscles and soften those vertical lines. Injections in other areas to improve appearance of facial lines have been reported in the literature, but the FDA has not approved those uses. The results of BOTOX® Cosmetic are usually dramatic, although the practice of medicine is not an exact science and no guarantees can be or have been made concerning expected results.

The BOTOX® Cosmetic solution is injected with a tiny needle into the muscle; you should see the benefits develop over the next two to seven days. A decreased appearance of frowning or creasing of other lines will be the result of this treatment.The most common side effects are headache, respiratory infection, flu syndrome, temporary eyelid droop, and nausea. BOTOX® Cosmetic should not be used if there is an infection at the injection site. Additionally, slight temporary bruising may occur at the injection site. I have been advised of the risks involved in such treatment, the expected benefits of such treatment, and alternative treatments, including no treatment at all.I understand that the results are temporary and several sessions may be needed for optimal results.I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs, and that I have had sufficient opportunity for discussion and to ask questions. I consent to this BOTOX ® Cosmetic treatment today and for all subsequent treatments.

Initials*

Signature*

(Patient Signature)

Witnessed by*

(Signature of Witness)

Date*

PATIENT CONSENT FORM