Botox & Dysport Consent Form
Name
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First Name
Last Name
Email
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example@example.com
Date of Birth
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Gender
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Male
Female
Address
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Street Address
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City
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Phone Number
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Medical History
If you have or have had any of the following, please check the box:
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Allergies
Conjunctivitis
Cardiovascular Disease
HIV/AIDS
Auto-Immune Disease
Cancer
Currently Breastfeeding
Currently Pregnant
Low Blood Pressure
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None of the above
Have you ever had Botox treatment before?
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Yes
No
Do you have any known allergies?
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Yes
No
If yes, what allergies?
Any recent surgeries? (in the last 6 months)
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Yes
No
If yes, what surgeries?
List any medications you take regularly
Treatment
Botox, also known as Botulinum Toxin, is an injectable treatment used to reduce wrinkles and fine lines on your face. It is derived from a natural protein produced by the bacterium Clostridium botulinum. When administered, Botox temporarily relaxes the muscles in the treated area, resulting in a smoother and more youthful appearance. Common areas where Botox is applied include the forehead lines, frown lines between the eyebrows, crow's feet around the eyes, and a brow lift. The Botox treatment can effectively reduce wrinkles and fine lines caused by repetitive muscle movements, giving your skin a smoother and more youthful look.
Risks and Complications
While Botox is generally considered safe and effective when administered by a trained and experienced healthcare professional, it is important to be aware of potential risks and complications associated with the treatment. Before proceeding with Botox treatment, it is essential that you understand and acknowledge the following:
-Temporary Side Effects: Following Botox injections, it is common to experience certain temporary side effects, which may include redness, swelling, bruising, tenderness, and mild pain at the injection site. These effects are usually mild and typically resolve on their own within a few days or weeks.
-Headache or Flu-like Symptoms: Following Botox treatment, you may experience a headache or flu-like symptoms, such as fatigue, muscle aches, or fever. These symptoms are usually mild and resolve within a few days.
-Allergic Reactions: Although rare, there is a possibility of developing an allergic reaction to Botox. Symptoms of an allergic reaction may include itching, rash, hives, swelling, dizziness, or difficulty breathing. If you experience any of these symptoms, it is crucial to seek immediate medical attention.
-Eyelid Drooping: In some cases, Botox injections near the eyes or eyebrows may cause temporary drooping of the eyelids. This condition, known as ptosis, may affect your vision or cause an asymmetrical appearance. The risk of eyelid drooping is typically low when administered by a skilled practitioner, but it is important to be aware of this potential complication.
Payment
I understand that this is an "elective” procedure and that payment is my responsibility and is expected at the time of treatment.
Right to Discontinue Treatment
I understand that I have the right to discontinue treatment at any time.
Results
It's crucial to understand that the results of the treatment can vary from person to person. While Botox is known for its ability to reduce wrinkles and lines, the extent of improvement and how long the results last can differ for each individual. Some people may experience a significant reduction in the appearance of wrinkles, resulting in a smoother and more youthful look, while others may notice more subtle changes. The duration of results typically ranges from a few months, after which the effects gradually diminish. It's important to have realistic expectations and understand that the outcome of your Botox treatment cannot be guaranteed.
Informed Consent
I understand this is an elective procedure and I hereby voluntarily consent to treatment with Botulinum Toxin for the reduction of wrinkles and fine lines. The procedure has been fully explained to me. I also understand that any treatment performed is between me and the doctor/healthcare provider who is treating me and I will direct all post-operative questions or concerns to the treating clinician. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure and I understand that no guarantees are implied as to the outcome of the procedure. I also certify that if I have any changes in my medical history I will notify the doctor/healthcare professional who treated me immediately. I also state that I read and write in English.
By signing below, you agree:
I release the medical staff including but not limited to the Dr. Nathan Holman, MD and Erin Decker, RN from any liability associated before, during, and after procedure. I have completed the form truthfully and to the best of my knowledge. I agree to inform the staff of any changes in the above information. I certify that I am a competent adult of at least 18 years of age and that this consent form is voluntarily executed.
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Photo and Video Release
I hereby grant and authorize RevIVed Mobile Infusions the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures, videos and /or audio taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social media sites and other print and digital communications, without payment or any other consideration.This authorization shall continue indefinitely and extends to all languages, media, formats and markets now known or later discovered.I waive any rights to royalties or other compensation arising or related to the use of the photograph or recording.I understand and agree that these materials shall become the property of RevIVed Mobile Infusions and will not be returned.I hereby hold RevIVed Mobile Infusions harmless and release from all liability, petitions, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons may make while acting on my behalf or on behalf of my estate.
By signing below, you agree:
I've read and fully understand the above model release agreement and agree to the terms and conditions set forth therein.
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