Consent for Use of Botulinum Toxin, Cosmetics

Botulinum toxin type-A, has different brand names as (Botox, Dysport, Xeomin, Botulax, Juveau others) and is a neurotoxin that blocks messages between muscles and the nerves that control them. The effects of the toxin become apparent 2-5 days after injection and generally last for 4-6 months. The FDA has approved the use of Botulinum Toxin to treat facial dystonias (spasms), strabismus (crossed eyes), and to temporarily soften facial rhytids (wrinkles) between the eyebrows. FDA has some approved injections to improve the appearance of wrinkles in other areas of the face, physicians may perform these “off-label” procedures. There are alternatives to Botulinum Toxin, including no treatment, or medicines or surgery on my facial nerves and muscles. Botulinum Toxin not is a filler product, the paralysis is temporary, and re-injection is necessary to maintain results within three to ten months.

Include but are not limited to:

1. Bruising
2. Under correction (not enough effect) or overcorrection (too much effect)
3. Facial asymmetry (one side looks different than the other)
4. Paralysis of a nearby muscle leading to: droopy eyelid, double vision, inability to close eye, difficulty whistling or drinking from a straw
5. Generalized weakness
6. Permanent loss of muscle tone with repeated injection
7. Flu-like syndrome or respiratory infection
8. Nausea or headache
9. Development of antibodies to Botulinum Toxin
10. Botulinum Toxin, contains human-derived albumin and carries a theoretic risk of virus transmission. There have been no reports of disease transmission through it.

You should not have or do injectable of Botulinum Toxin if: you are pregnant; nursing; allergic to albumin or any other component of the product; have an infection, skin condition, or muscle weakness at the site of the injection or by any specific disease as Eaton-Lambert syndrome, Lou Gehrig’s disease, or Myasthenia Gravis or Gillan Barre.

I understand the above, and have had the risks, benefits, and alternatives explained to me. No guarantees about results have been made. I give my informed consent for Botulinum Toxin injections today as well as future treatments as needed.

I give my consent for Botulinum Toxin injections into the face, head and neck muscles determined appropriate by the health personal or doctor, temporarily paralyzing these muscles, to decrease the appearance of expression lines and wrinkles in facial, head and neck areas.Although the results are usually dramatic, I understand that no guarantees can be or have been made concerning expected results in my case.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 agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.I understand that side effects and complications are rare, but may include temporary headache, local numbness, and rash. Occasionally, slight swelling, and/or bruising may occur and last for several days after the injections. Rarely, an adjacent muscle may be weakened for several weeks after an injection.

I approve my injectable* and authorize to Type Name* , personal from Caras Facial Center LLC, to do my procedure.

Print Name*

Signature*

(Patient Signature)

MD/Medical Representative*

(Signature of MD/Medical Representative)

Date*

Consent for Use of Botulinum Toxin, Cosmetics

INDICATIONS AND ALTERNATIVES

SIDE EFFECTS AND COMPLICATIONS

CONTRAINDICATIONS

CONSENT: