Botox, Dysport, Xeomin or Jeuveau Therapy Consent Form

Full Name*

First NameLast Name

Date

MonthDayYear

Any changes in your medical history?

YesNoOther

Proposed treatment injection of Botox (onabotulinumtoxinA), Dysport (abobotulinumtoxinA), Xeomin (incobotulinumtoxinA) or Jeuveau (prabotulinumtoxinA-wvfs) into a specific muscle. The result is weakness of the muscle and improvement of the lines or wrinkles that the muscle action has formed. Anticipated benefit response is usually seen 2-14 days after injection. Typically, the muscle action (and wrinkles) will return in 2-4 months. At this point, a repeat treatment will relax the muscle and soften the lines again.

I understand that several sessions may be needed to complete the injection series. I understand that there is a separate charge for any subsequent treatment. Touch-ups/follow ups are done 12-21 days after initial treatment.

Risks and complications, possible side effects include: Transient headache, swelling, bruising, pain during injection, twitching, itching, numbness, asymmetry, temporary dropping of eyelids or eyebrows. These side effects are rare, but have been reported. In a very small number of individuals, the injection does not work as satisfactory. Known significant risks have been disclosed, yet the theoretical risk of unknown complications does exist. Substances that increase the risk of bruising include Vitamin E, Asprin, Motrin, Coumadin, other non-steroidal anti-inflammatory drugs and blood thinners. I understand that if I have taken any of the above in the past 7 days, I have an increased risk of bruising. I understand that if I am taking a blood thinning medication, this treatment may result in significant bruising and may not be recommended.

I attest that I have provided my medical provider with a list of all my current medications and supplements. I understand that there may be a higher possibility of side effects if I do not follow certain instructions. I will adhere to these instructions for at least 4 hours from the time of a treatment. These include:

● I will refrain from exercise or activity that will increase heart rate.

● I will not lie down or bend down forward for extended periods of time.

● I will not manipulate or massage the treated area.

Pregnancy and Neurological Disease:

● I understand that there are certain conditions where Botox, Dysport, Xeomin, or Jeuveau treatments are not recommended. These include neurological diseases such as myasthenia gravis, Eaton-Lambert syndrome, and Lou Gehrig’s Disease.

● If pregnant or breastfeeding I will not undergo treatment.

Limitations: Botox, Dysport, Xeomin or Jeveau is best at treating dynamic facial lines, those caused by facial muscle activity; lines present at rest may or may not improve. A treatment may be effective for variable lengths of time with subsequent treatments, which may not work as well or for as long as expected.

Cost/Fees/Payment for this cosmetic procedure is my responsibility. I understand that there will be an additional fee for touch ups. Because Botox, Dysport, Xeomin, or Jeuveau is a cosmetic procedure, insurance will not cover, nor do Timeless Beauty Aesthetics accept insurance. Payment is requested at time of service. Under no circumstance will there be refunds, transfers or credits once treatment has been administered.

I grant permission and consent to Timeless Beauty Aesthetics for the use of the following photograph(s) as identified below for presentation under any legal condition, including but not limited to: publicity, copyright purposes, illustration, advertising, and web content.

I have read the above, understand and authorize this consent. I accept the risks and complications of the procedure.

I have read the above, understand and authorize this consent. I accept the risks and complications of the procedure. *

Yes

I assume all risks as my own and agree to hold harmless, Timeless Beauty Aesthetics and their providers, and any other staff member affiliate, or independent contractor. I hereby release them from any liability, both seen and unforeseen, now and forever. Do not receive BOTOX® Cosmetic if you: are allergic to any of the ingredients in BOTOX® Cosmetic (see Medication Guide for ingredients);had an allergic reaction to any other botulinum toxin product such as Myobloc®(rimabotulinumtoxinB), Dysport® (abobotulinumtoxinA), Xeomin®(incobotulinumtoxinA) or Jeuveau (prabotulinumtoxinA-wvfs); have a skin infection at the planned injection site. Tell your doctor about all your muscle or nerve conditions,such as ALS or Lou Gehrig’s disease, myasthenia gravis, or Lambert-Eatonsyndrome, as you may be at increased risk of serious side effects including difficulty swallowing and difficulty breathing from typical doses of BOTOX®Cosmetic.

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