Starlight Aesthetics
Neuromodulator Informed Consent
Botulinum Toxin Type A
Treatment Overview
Neuromodulators are injectable medications containing botulinum toxin type A used to temporarily relax targeted muscles to soften the appearance of facial lines and wrinkles. Results are temporary and vary by individual.
Potential Benefits
Potential benefits include a smoother, more relaxed appearance, prevention of wrinkle progression, and subtle, natural-looking results when appropriately administered.
Risks and Possible Side Effects
Common side effects may include redness, swelling, bruising, headache, tenderness, or tightness at injection sites. Less common risks include eyelid or brow drooping, facial asymmetry, muscle weakness near the injection site, dry eye, or changes in facial expression. Rare but serious risks include difficulty swallowing, speaking, or breathing, allergic reaction, or unintended spread of the medication to adjacent muscles.
Who Should Not Receive Neuromodulators
Neuromodulator treatment may not be appropriate if you are pregnant or breastfeeding; have a neuromuscular disorder (such as myasthenia gravis or ALS); have an active infection at the treatment site; or have had a previous allergic reaction to botulinum toxin products.
Alternatives to Treatment
Alternatives include no treatment, topical skincare, energy-based devices, dermal fillers, or surgical procedures. I understand that I may choose not to proceed with neuromodulator treatment.
Expectations and Aftercare
I understand that results are not immediate and may take up to 10-14 days to fully develop. Results are temporary and maintenance treatments may be required. I agree to follow all post-treatment instructions provided by my provider.
Patient Acknowledgment & Consent
I confirm that I have disclosed my complete medical history, medications, and supplements. I have had the opportunity to ask questions and all questions have been answered to my satisfaction. I understand the benefits, risks, and alternatives of neuromodulator treatment and voluntarily consent to treatment.
Patient Name:
Patient Signature:
Date:
-
Month
-
Day
Year
Date
Provider Signature:
Date:
-
Month
-
Day
Year
Date
Preview PDF
Submit
Should be Empty: