INFORMED CONSENT-BOTOX

INFORMED CONSENT-BOTOX
You have both the right and responsibility to make decisions concerning your healthcare. The physician shall provide you with the necessary information but as a member of the healthcare team it is essential that you enter into the decision-making process. This form has been designed to document your informed consent to the procedure(s) that you have discussed with your physician.

I, First Name* Last Name* Date of Birth* hereby authorize Dr. Annie Pinto to perform Botox (Botulina Type A Toxin) Injections.
Specific Risks of Botox (Botulina Type A Toxin) Injections

Please read and check each box below.
Incomplete result: It is possible to not obtain a complete result in targeted muscles. Additional injections to reach the desired level of result can be performed until the goal is achieved.*

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Drooping Eyelid (Ptosis): Muscles that raise the eyelid maybe affected by Botox, should this material migrate downward from other injection areas. If this problem occurs, it is temporary and additional treatments such as eye drops maybe necessary.*

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Migration: Botox may migrate from its original injection site to other areas and produce temporary weakness of the other muscle groups or other unintended effects.*

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Allergic Reactions: As with all biologic products, allergic and systemic anaphylactic reactions may occur. Allergic reactions may require additional treatment.*

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Pregnancy and Nursing Mothers: Animal reproduction studies have not been performed to determine whether Botox causes fetal harm. It is not known whether Botox can be excreted in human milk. It is not recommended that pregnant women or nursing mothers receive Botox treatments. Please inform your surgeon prior to proceeding if you are pregnant or nursing.*

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Asymmetry: The human face and eyelid region are normally asymmetrical with respect to structural anatomy and function. There can be a variation from one side to the other in terms of the response to the injection.*

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Pain: Discomfort associated with the injections is usually of short duration.*

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Bleeding and Bruising: Bruising in soft tissues may occur. Aspirin, anti-inflammatory medications, anticoagulants,Vitamin E, Ginkgo biloba, and other homeopathic remedies may contribute to a greater risk of a bleeding problem. Do not take these for ten days before the injections. If you are taking these medications, please inform your surgeon prior to proceeding.*

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Neuromuscular Disorders: Patients with peripheral motor neuropathic disorders may be at greater risk of clinically significant side effects from Botox.*

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INFORMED CONSENT-BOTOX

Specific Risks of Botox (Botulina Type A Toxin) Injections

Authorized Consent