I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment prior to receiving services.
I further agree that, in the event of non-payment, cancellation of payment, or any payment issues, I will bear the cost of collection, and/or court costs and legal fees, should those be required.
I consent to being signed up for rewards programs so I can earn free points to get discounts on my treatments.
I consent to email, text, and phone communications related to post-procedure care and follow-ups.
I am not aware that I am pregnant, am not trying to get pregnant, and am not lactating (nursing).
I do not have, nor have I had, any major illnesses that would prohibit me from receiving this treatment.
I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to lidocaine.
I am of sound mind and fully aware of all the risks and possible complications of this procedure.
I understand this procedure is one hundred percent voluntary.
I acknowledge that no guarantee has been given regarding the results that may be obtained.
I have read the material given to me and am fully satisfied that all of my questions and concerns have been addressed.
I understand that I am required to attend post-procedure check-ups as advised by the provider and that I must follow all post-treatment instructions.
I have received and fully understand the pre-treatment instructions, will follow post-treatment instructions, and have had the opportunity to ask any questions relating to this procedure.
I have advised my provider of my medical history, including all previous medical conditions and medications currently being taken.
Alternatives to the procedures and options I am choosing to receive today have been fully explained to me.
I consent to the administration of any anesthetics considered necessary or advisable. I understand that all forms of anesthesia involve risks and the possibility of complications or injury.
I am aware that there may be other risks or complications not discussed that may occur.
I also understand that during the course of the proposed procedure, unforeseen conditions may be revealed, requiring the performance of additional procedures. I authorize such procedures to be performed.
I acknowledge that no guarantees or promises have been made to me concerning the results of this procedure or any treatment that may be required as a result of this procedure.
I understand there are no refunds and that multiple treatments are often required to achieve noticeable and lasting outcomes. I also understand that promotional items have no refund value.
By accepting and signing, I acknowledge that I have read this informed consent, understand it, and agree to the treatment with its associated risks. I hereby give consent to perform this and all subsequent treatments with the above understood. I hereby release the Medical Director(s), the provider performing the treatment, and the clinic from liability associated with this procedure. I have been given the opportunity to ask questions, and my questions have been answered to my satisfaction. I also state that I read and write in English.
I hereby consent to the Botulinum Toxin Injection Treatment and authorize the provider to perform the Botulinum Toxin Injection Treatment. I understand that I will be injected with Botulinum A Toxin in the area of the facial muscles to temporarily paralyze these muscles, or in the forehead or crow’s feet area around the lateral area of the eyes. I understand my treatment may include both FDA-approved locations as well as commonly performed cosmetically treated areas based on desired effects.
Botulinum A Toxin injection has been FDA-approved for use in the cosmetic treatment of glabellar frown lines — the wrinkles between the eyebrows — and crow’s feet. I understand there are other risks for the non-FDA-approved uses of Botulinum A Toxin. Injection of Botulinum A Toxin into the small muscles between the brows causes those specific muscles to halt their function (be paralyzed), thereby improving the appearance of the wrinkles.
I understand the goal is to decrease the wrinkles in the treated area. This paralysis is temporary and typically lasts three to four months, although longevity varies among individuals. It has been explained to me that other alternatives are available.
The possible side effects of Botulinum A Toxin include, but are not limited to:
Local numbness, rash, pain at the injection site, flu-like symptoms, and headache.
Infection: Infections can occur, which in most cases are easily treatable but, in rare cases, can result in permanent scarring in the area.
Bruising may occur and last several weeks.
Most people have slightly swollen, pinkish bumps at injection sites for a couple of hours or even several days.
Although many people with chronic headaches or migraines often get relief from Botulinum A Toxin, a small percentage of patients experience headaches following treatment with Botulinum A Toxin, most commonly within the first 1–7 days. In a very small percentage of patients, these headaches can persist for several days or weeks. Respiratory problems such as bronchitis or sinusitis, nausea, dizziness, and tightness or irritation of the skin may also occur.
While local weakness of the injected muscles is representative of the expected pharmacological action of Botulinum A Toxin, weakness of adjacent muscles may occur as a result of the spread of the toxin.
Treatments: I understand more than one injection may be needed to achieve a satisfactory result. Another risk when injecting Botulinum A Toxin around the eyes includes corneal exposure because people may not be able to blink the eyelids as often as they should to protect the eye. This inability to protect the eye has been associated with damage to the eye, impaired vision, or double vision, which is usually temporary.
This reduced blinking has been associated with corneal ulcerations. There are medications that can help lift the eyelid; however, if the drooping is too great, the eye drops are not as effective. These side effects can last several weeks or longer. This occurs in 2–5 percent of patients.
I will follow all aftercare instructions, as it is crucial I do so for healing.
As Botulinum A Toxin injection is not an exact science and facial anatomy and symmetry are highly variable from patient to patient, there might be an uneven appearance of the face with some muscles more affected by the Botulinum A Toxin than others. In most cases, this uneven appearance can sometimes be corrected by injecting Botulinum A Toxin in the same or nearby muscles. However, in some cases, this uneven appearance can persist for several weeks or months until the full effects of the product have subsided.
This list is not meant to be inclusive of all possible risks associated with Botulinum A Toxin, as there are both known and unknown side effects associated with any medication or procedure. Botulinum A Toxin should not be administered to a pregnant or nursing woman.
Additionally, the number of units injected is an estimate of the amount of Botulinum A Toxin required to paralyze the muscles. I understand there is no guarantee of results from any treatment. As with all injectable treatments, there is a risk of infection, vessel occlusion, granulomas, abscess formation, and hypersensitive reaction.