Botulinum Toxin Consultation and Consent Form Logo

  • Botulinum Toxin Consultation and Consent Form

  • Treatments are performed by Brooke Mendenhall under the direct supervision of Medical Director Johnathan Walker

    ALL ABOUT YOU - 528 Gracie St. Dublin, Texas - (254) 445-0315
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  • Medical History

  • Emergency Contact Details

  • Neurotoxin Treatment

    Neurotoxins blocks nerve signals to muscles. As a result, injected muscles can’t contract (tense up). These effects are always temporary, but can last for several months. The muscle injected depends on the primary area of concern. Several areas can be treated in one session. The results can often be seen start 3-7 days after treatment but can take up to 14 days to see final results.If have any questions regarding the procedure, ask trainer prior to signing the consent form.

  • Possible Side Effects

    This list is not meant to be inclusive of all possible risks associated with Botulinum Toxin as there are both known and unknown side effects associated with any medication or procedure.The possible side effects of Botulinum Toxin include, but are not limited to:- Allergic reactions- Headache- Temporary drooping of facial features- Double or blurred vision- Asymmetry- Neck or back pain- Difficulty swallowing- Muscle weakness where the medicine was injected- Injection site reactions - i.e. bruising, bleeding, pain, redness, swelling, infection or tenderness- Flu symptoms- Dizziness- Dry, itchy, or watery eyes- Swelling or bruisingPlease note: Most people will have slightly swollen, pinkish bumps where the injections went in, for a couple of hours or even several days after the treatment.If you have concerns about any side effects please seek medical advice.

  • Aftercare Advice

    Please read carefully. The goal of aftercare is to encourage optimal treatment results. It can also minimize the risk of bruising and spreading to other areas. Follow the aftercare advice provided for optimal results. Don’t touch your skin. Take a break from makeup for 24 hours and don't touch your face. Applying makeup will rub the skin, potentially dispersing the toxin. If you got Botulinum Toxin in another part of your body, you should also avoid touching those areas. This includes professional massages on the treated areas. It’s best to schedule your next massage several days later. Wait 24 hours to exercise. If exercise is part of your daily routine, wait at least 24 hours to work out. Physical activity increases blood flow. This could potentially spread the toxin to unintended areas and reduce its effectiveness at the injection site. It also increases the risk of bruising. Exercise also contracts your muscles, which may decrease the toxin’s effectiveness.Sit up. Sit up for the first 4 hours after getting Botulinum Toxin. Bending or lying down might spread the toxin and promote bruising.Medication. Some medications might increase your risk of bruising. Be sure to ask your practitioner when it’s safe to start taking them again. Avoid aspirin and ibuprofen for a few days following treatment. Do not restart Retinol or Retin-A for 2 days.Don’t drink alcohol. Alcohol increases the risk of bruising. Wait at least 48 hours after your treatment before consuming alcohol.Don't massage, rub or apply pressure to the treated area.Don’t sleep on the treated areas. Try your best to avoid sleeping on the injected areas. This will minimize the physical pressure and let the Botulinum Toxin settle into your muscles. Also, avoid sleeping within 4 hours after your procedure.Stay out of the sun. Avoid sun exposure for at least 48 hours. The heat can promote flushing and increase your blood pressure, which may encourage bruising.Avoid heat exposure. It’s also best to avoid other forms of heat exposure, such as: Tanning bed, Hot tubs, Hot showers or baths and Saunas.Apply ice. You can apply a pack of ice for relief. The bruising should go away in about 2 weeks.Apply topical cream. You can apply Arnica cream to any areas with redness, bruising or swelling.Avoid waxing and use of chemical depilatories for 1 week following treatment.Wait before having more Aesthetic treatments. Avoid facials, chemical peels, micro-dermabrasion for 2 weeks following treatment. Radio frequency miconeedling must be avoided for 4 weeks.

  • Consent

    I accept that any treatment I am going to receive is at my own risk.I certify that I have read, fully understood, and completed this form to the best of my knowledge.I understand that failure to disclose information requested above may result in adverse side effect(s), unknown because of this to which I accept full liability/responsibility.The treatment(s) and possible side effect(s) have been fully explained to me. I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request.I accept that if I am not satisfied with the treatment I will inform the practitioner immediately.BOTOX® Cosmetic ConsentI hereby authorize Dr. Fobi and his practitioner Brooke Mendenhall to treat me using Xeomin or BOTOX Cosmetic intramuscular injections.   Xeomin or BOTOX® Cosmetic is a purified protein produced by the botulinum toxin that will be injected into the muscles in the treatment area to cause temporary weakness or paralysis of those muscles. The purpose of this procedure is to temporarily improve the appearance of moderate to severe frown lines between the brows.  The effect most often appears between 7-10 days after treatment.  However, the maximum relaxation is not complete until 10-14 days after the injection.  Results can last up to four months.  Most clients find that 3 to 4 treatments are needed each year for optimum results.  With time and continued treatments, results may begin to last longer.Some discomfort may be experienced during the treatment and will vary from person to person.  The sensation is most commonly compared to a bug bite.  Some people may choose to have the treatment area numbed with a cold pack, prior to injecting.Localized pain, infection, inflammation, tenderness, swelling, redness, and/or bleeding/bruising may be associated with the injection.  A rare side effect after treatment may include a minor temporary droop in one eyelid that usually lasts less than three weeks or nausea.Injectable Xeomin or BOTOX® Cosmetic should not be used in people who are pregnant or breastfeeding. Let your practitioner know if you have any neuromuscular disorder that may increase your risk of serious side effects.  It is your responsibility to disclose your complete medical history to Northwest Aesthetics. Xeomin  BOTOX® Cosmetic has been in clinical use for many years and is now approved by the FDA for cosmetic use.  The studies upon which the approval is based were limited to the corrugator muscle (glabella).  Therefore, use in all other areas is, strictly speaking, off label.  This does not mean other areas are contraindicated, rather it is disclosed as part of this consent process.

  • Blindness-Although extremely rare, aesthetic injectables can cause permanent blindness by blocking the blood supply to the eye.  The higher risk areas are around the glabella (the skin between the eyebrows and above the nose), nasal region, nasolabial folds, and forehead.  The most common symptoms are immediate vision loss and pain.  Central nervous system complications related to the blindness can occur.

     


    All manufacturers required safety precautions for this procedure will be followed to ensure the utmost in safety during your treatments.  A copy of the medication guidelines provided by the manufacturers of Xeomin or BOTOX® Cosmetic is available for your review upon request.

    This consent shall apply to all subsequent Xeomin or BOTOX® Cosmetic injection treatments.

    While every reasonable effort will be made to achieve the desired outcome, no guarantees of results from this treatment are stated or implied.

     


    The cost of injection may involve several charges. This includes the professional fee for the injections, follow up visits to monitor the effectiveness of the treatment, and the cost of the material itself.  It is unlikely that injections to treat cosmetic problems would be covered by your health insurance. Additional costs of medical treatment would be your responsibility if complications develop from this treatment.

     

     

    I certify that I am a competent adult at least 18 years of age. By signing below, I certify that I have read and fully understand the contents of this consent form for the procedure and that the disclosures referred to herein were made to me.  I understand and acknowledge that payments for the above procedure are non-refundable.

     

     

    I fully understand the above and consent to receive Botulinum Toxin.

     


    THIS FORM ALSO APPLIES TO ALL FUTURE TREATMENTS 

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  • Media Consent

    From time to time we may want to take photos or/and videos before, during and after your treatment. We may want to use these photos / videos for educational and promotional purposes including, but not limited to, staff training materials, newsletters, flyers, website, printed advertisements, digital advertisements, social networking sites and other print or digital communications.I consent to the use of photos and videos as indicated by me on this form.I understand I can revoke this at any time by contacting the clinic directly. I can confirm that I have read, or been made aware of how these photos or / and videos will be stored within the organization.Please use this form to confirm for which purposes we have the right to use photos or/and videos of you.
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