Botox (Botulinum A Toxin) Informed Consent printable pdf download

BOTOX ( B o t u l i n u m A Toxin) INFORMED CONSENT

I, ______________________________________________________, understand that I will

be injected with Botulinum A Toxin (Botox) in the area of the glabella muscles to paralyze

these muscles temporarily or in the forehead or crows feet around the lateral area of the eyes.

Botulinum A Toxin (Botox) injection has been FDA approved for use in the cosmetic treatment for

glabellar frown lines only – the wrinkles between the eyebrows.

Injection of Botox 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 re-injection is

necessary within three to four months. It has been explained to me that other temporary and more

permanent treatments are available.

The possible side effects of Botox include but are not limited to:

1. Risks: I understand there is a risk of swelling, rash, headache, local numbness, pain at

the injection site, bruising, respiratory problems, and allergic reaction.

2. Infection: Infections can occur which in most cases are easily treatable but in rare cases a

permanent scarring in the area can occur.

3. Most people have lightly swollen pinkish bumps where the injections went in, for a couple of

hours or even several days.

4. Although many people with chronic headaches or migraines often get relief from Botox, a

small percent of patients get headaches following treatment with Botox, for the first day. In a

very small percentage of patients these headaches can persist for several days or weeks.

5. Local numbness, rash, pain at the injection site, flu like symptoms with mild fever, back pain.

6. Respiratory problems such as bronchitis or sinusitis, nausea, dizziness, and tightness or

irritation of the skin.

7. Bruising is possible anytime you inject a needle into the skin. This bruising can last for

several hours, days, weeks, months and in rare cases the effect of bruising could be

permanent.

8. While local weakness of the injected muscles is representative of the expected

pharmacological action of Botox, weakness of adjacent muscles may occur as a result of the

spread of the toxin.

9. Treatments: I understand more than one injection may be needed to achieve a satisfactory

result.

Botox (Botulinum A Toxin) Informed Consent