Neurotoxin Consent

Name

First NameLast Name

Date of Birth

Date

Introduction

You have requested to receive neurotoxin injections at our medical spa. This form provides important information about the procedure, including the risks, benefits, and alternatives to the procedure name above, and confirms your consent to proceed. Please read the following information carefully, ask any questions you may have, and sign where indicated.

Description of the Procedure

Neurotoxin injections are used to reduce the appearance of dynamic wrinkles by temporarily paralyzing the underlying muscles. The procedure involves the injection of a neurotoxin into targeted muscles, resulting in a smoother appearance of the skin.

Indications for Treatment

The procedure is indicated for the treatment of:

-Forehead lines
-Glabellar lines (frown lines between the eyebrows)
-Crow's feet (lines around the eyes)

Potential Risks and Side Effects

While neurotoxin injections are generally safe, potential risks and side effects include:

-Bruising at the injection site
-Swelling or redness
-Headache
-Drooping of the eyelid or eyebrow
-Allergic reactions (rare)
-Infection (rare)

Contraindications

You should not receive neurotoxin injections if you:

-Have neuromuscular disorders (e.g., myasthenia gravis)
-Are allergic to any component of the neurotoxin
-Are pregnant or breastfeeding
-Have an active skin infection at the injection site

Alternatives to Treatment

Alternative treatments to neurotoxin injections include:

-Dermal fillers
-Chemical peels
-Laser therapy
-Topical treatments

Pre-Treatment Instructions

-Avoid blood thinners (e.g., aspirin, ibuprofen) for at least 24 hours before the procedure to minimize bruising.
-Refrain from alcohol consumption for 24 hours prior to treatment.
-Inform your provider of any medications or supplements you are currently taking.

Post-Treatment Care

-Avoid rubbing or massaging the treated area for at least 24 hours.
-Stay upright and avoid strenuous exercise for the first 4 hours after treatment.
-Follow all aftercare instructions provided by your provider.

Payment Responsibility

I understand that this is an “elective” procedure and that payment is my responsibility and is expected at the time of treatment.

Acknowledgment and Consent

I have read and understood the information provided above regarding neurotoxin injections. I have had the opportunity to ask questions and have received satisfactory answers. I understand the risks, benefits, and alternatives to the procedure. I consent to the administration of neurotoxin injections as described.

Have you received neurotoxin injections in the past?

If you answered "yes" to the question above, please indicate where and when neurotoxin injections were received.

I consent to the neurotoxin injections procedure.

I acknowledge that I have been informed about the potential risks and benefits of the treatment.

I am not aware that I am pregnant. I am not trying to get pregnant. I am not lactating (nursing). I do not have or have not had any major illnesses which would prohibit me from receiving neurotoxin injections. I certify that I do not have multiple allergies or high sensitivity to medications, including, but not limited to, lidocaine or other local anesthetics.

I agree to follow the pre-treatment and post-treatment instructions provided by my Fab Fusion provider.

I understand that results may vary and that no guarantees of outcome have been made.

I understand that I have the right to discontinue treatment at any time.

BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ THE FOREGOING CONSENT IN ITS ENTIRETY AND AGREE TO THE TREATMENT AND ITS ASSOCIATED RISKS. I HEREBY GIVE CONSENT TO PERFORM THIS AND ALL SUBSEQUENT NEUROTOXIN INJECTION TREATMENTS WITH THE ABOVE UNDERSTOOD UNTIL AND UNLESS I WITHDRAW MY CONSENT. I HEREBY RELEASE FAB FUSION AESTHETICS FROM ALL LIABILITIES ASSOCIATED WITH THIS PROCEDURE.

Signature

Date

Form

Neurotoxin Consent