Consent To Botox Form in Circleville, OH

Patient*

First Last

Date Of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Botox® is a neurotoxin produced by the bacterium Clostridium A. Botox® can relax the muscles on areas of the face and neck which cause wrinkles associated with facial expressions. Treatment with Botox can cause your facial expression lines or wrinkles to essentially disappear. Areas most frequently treated are: a) glabellar area of frown lines, located between the eyes; b) crow’s feet (lateral areas of the eyes); and c) forehead wrinkles. Botox is diluted to a very controlled solution and when injected into the muscles with a very thin needle, it is almost painless. Clients may feel a slight burning sensation while the solution is being injected. The procedure takes about 15-20 minutes and the results last 3-6 months. With repeated treatments, the results may tend to last longer. (INITIAL)*

RISKS AND COMPLICATIONS

It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure and in this specific instance such risks include but are not limited to: 1.Post treatment discomfort, swelling, redness, and bruising, 2. Double vision 3. A weakened tear duct 4. Post treatment bacterial, and/or fungal infection requiring further treatment 5. Allergic reaction 6. Minor temporary droop of eyelid(s) in approximately 2% of injections, this usually lasts 2-3 weeks 7. Occasional numbness of the forehead lasting up to 2-3 weeks, 8. Transient headache, and 9. Flu-like symptoms may occur. (INITIAL)*

PUBLICITY MATERIALS

I authorize the taking of clinical photographs and videos and their use for scientific and marketing purposes both in publications and presentations. During courses given by Common Sense Dentistry and/or The American Academy of Facial Esthetics (AAFE), I understand that photographs and video may be taken of me for educational and marketing purposes. I hold the AAFE harmless for any liability resulting from this production. I waive my rights to any royalties, fees and to inspect the finished production as well as advertising materials in conjunction with these photographs.*

PUBLICITY MATERIALS PREGNANCY, ALLERGIES & NEUROLOGIC DISEASE

I am not aware that I am pregnant and I am not trying to get pregnant, I am not lactating (nursing). I do not have any significant neurologic disease including but not limited to Myasthenis Gravis, Multiple Sclerosis, Lambert-Eaton Syndrome, Amyotrophic Lateral Sclerosis (ALS), Parkinson’s. I do not have any allergies to the toxin ingredients, or to human albumin. (INITIAL)*

PAYMENT

I understand that this is an "elective” cosmetic procedure and that payment is my responsibility and is expected at the time of treatment. (INITIAL)*

RIGHT TO DISCONTINUE TREATMENT

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

ALTERNATIVE PROCEDURES

Alternatives to the procedures and options that I have volunteered for have been fully explained to me.*

RESULTS

I am aware that when small amounts of purified botulinum (“BOTOX”) are injected into a muscle it causes weakness or paralysis of that muscle. This appears in 2 – 10 days and usually lasts 3-6 months but can be shorter or longer. In a very small number of individuals, the injection does not work as satisfactorily or for as long as usual and there are some individuals who do not respond at all. I understand that I will not be able to “frown” while the injection is effective but that this will reverse after a period of months at which time re-treatment is appropriate. I understand that I must stay in the erect posture and that I must not manipulate the area (s) of the injections for the 2 hours post-injection period.*

I understand this an elective procedure and I hereby voluntarily consent to treatment with Botox® injection for Facial Dynamic Wrinkles, TMJ, or Bruxism. The procedure has been fully explained to me. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure and I understand that no guarantees are implied as to the outcome of the procedure. I also certify that if I have any changes in my medical history I will notify the office immediately. I also state that I read and write in English. (Signature)*

Print Name*

First Last

Date*

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.