Face It

Patient Name:*

Botulinum Toxin, a neurotoxin produced by the bacterium Clostridium A, can relax the muscles on areas of the face which cause wrinkles associated with facial expressions. Treatment with Botox, Dysport * or other similar injectables (hereinafter, "purified botulinum") can cause our facial expression lines or wrinkles to essentially disappear. Areas most frequently treated are: (a) glabellar area of frown lines located between the eyes; (b) crow's feet, the lateral area of the eyes; and (c) forehead wrinkles. Purified botulinum is diluted to a very controlled solution and when Injected into the muscles with a very thin needle, 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 typically last from 3 to 6 months. With repeated treatments, results may last longer In some individuals.

Potential Risk and Side Effects

It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure and in the specific instance such risks include, but are not limited to:

Post-treatment discomfort, swelling, redness, and bruising: Initial Here*.

Post treatment bacterial, viral, and/or fungal infection requiring further treatment:Initial Here*.

Allergic reaction: Initial Here* .

Minor temporary droop of the eyelid(s) in approximately 2% of injections, this could last 2 to 3 weeks: Initial Here*.

Occasional numbness of the forehead, this could last 2 to 3 weeks: Initial Here* .

Transient headache: Initial Here* .

Flu-like symptoms: Initial Here*.

On occasion, we provide off-label procedures or procedures that are not FDA-approved: Initial Here* .

Proposed Treatment Result
The practice of medicine and surgery is not an exact science and therefore reputable practitioners cannot guarantee results. While the overwhelming number of patients have gratifying results from injections, we cannot promise or guarantee specific results. I am aware that when small amounts of purified botulinum are injected into a muscle it causes weakness or paralysis of thai muscle. This typically appears in 3 to 7 days and usually last 3 to 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 while the injection is effective, I will not be able to move certain facial muscles that have been treated but this will reverse after a period of months at which time re-treatment is appropriate. I understand that J must avoid lying down and must manipulate the area of the injection for at least four hours post treatment. I consent to photographs being taken to evaluate treatment effectiveness, for medical education, training professional publications or sales purposes. No photographs revealing my identity will be used without my written consent. If my identity is not revealed, photographs may be used and displayed publicly without my permission.

Informed Consent

By signing below, I acknowledge that I have read the foregoing information and understand the risks of purified botulinum. I voluntarily consent and authorize that this treatment be performed by the healthcare providers of Face It. I hereby release staff and any other participating healthcare providers from any and all liability for any adverse effects that may result from this treatment and related procedures. I hereby consent to treatment.

Patient Signature*

Date

Medical Staff Signature (MD,PA,APRN,RN)

Date

Botulinum Toxin "A" Treatment Consent Form