Botox®, Dysport and Jeuveau are neurotoxins produced by the bacteriumn Clostridium A. All neurotoxins can relax the muscles on areas of the face and neck which cause wrinkles associated with facial expressions. Treatment with neurotoxin can cause your facial expression lines or wrinkles to essentially disappear. Areas most frequently treated are: 1) glabellar area(or frown lines) located between the eyes; 2) crow’s feet (lateral areas of the eyes); and 3) forehead wrinkles.
Neurotoxin is diluted to a very controlled solution and, when injected into the muscles with a very thin needle, it is almost painless. Clients may feel a slight burning sensation while the solution is being injected. The procedure takes about 15-20 minutes and the results last 3-6 months. With repeated treatments, the results may tend to last longer.
Risks and Complications – It has been explained to me that there are inherent and potential risks and side effects in any invasive procedure and in this specific instance, such risks include, but are not limited to: 1) post-treatment
discomfort, swelling, redness and bruising; 2) post-treatment bacterial and/or fungal infection requiring further treatment; 3) allergic reaction; 4) minor temporary droop of eyelid(s) in approximately 2% of the injections given
(this usually lasts 2-3 weeks); 5) occasional numbness of the forehead lasting up to 2-3 weeks; 6) transient headache; 7) flu-like symptoms may occur.
Photographs – I authorize the taking of clinical photographs and their use for scientific purposes both in publications and presentations. I understand my identity will be protected.
Pregnancy, Allergies and Neurological Disease – I am not aware that I am pregnant nor am I trying to get pregnant. I am not lactating (nursing) nor do I have any significant neurological diseases including, but not
limited to: Myasthenia Gravis, Multiple Sclerosis, Lambert-Eaton Syndrome, Amyotrophic Lateral Sclerosis (ALS), or Parkinson’s. I have no allergies to the toxin ingredients or to human albumin.
Payment – I understand that this procedure is cosmetic and that payment is my responsibility.
Results – I am aware that when small amounts of purified botulinum (neurotoxins) are injected into a muscle, it causes weakness or paralysis of that muscle. This appears in 2-7 days and usually lasts 3-6 months but can be shorter
or longer. In a very small number of individuals, the injection does not work as satisfactorily or for as long as usual. I understand that I will not be able to “frown” while the injection is effective but that this will reverse after a period of months at which time re-treatment is appropriate. I understand that I must stay in the erect posture and that I must not manipulate the area of the injection for the 4 hours post-injection period.
I hereby voluntarily consent to receive treatment with neurotoxin (Botox®, Dysport and Jeuveau) injections for the condition known as FacialDynamic Wrinkles. The procedure has been explained to me. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure. I certify that if I have any changes occurring in my medical history, I will notify the office.