Botox Consent Form - Doctors Of Internal Medicine printable pdf download

DOCTORS OF INTERNAL MEDICINE

PATIENT BOTOX CONSENT FORM

Patient Name: _______________________________ Date of Treatment ___________________

Being fully informed about your condition and treatment will help you make the

decision whether or not to undergo BOTOX® Cosmetic treatment. It is simply an effort

to better inform you so that you may accept or withhold your consent for this

treatment.

I have requested that Dr. _________________ attempt to improve my facial lines and

enhance facial shaping with BOTOX® Cosmetic. This is the Allergan, Inc. trademark for

Botulinum Toxin Type A. These injections have been used for nearly two decades to

improve spasm of the muscles around the eye, to correct double vision due to muscle

imbalance, as well as numerous other neurological uses.

BOTOX® Cosmetic cannot be given if you are pregnant, breastfeeding, on blood

thinners, or have any neurological diseases; such as MS or myasthenia gravis. The

effects of the medication may be greater than expected if you are taking certain

aminoglycoside antibiotics, such as gentamycin, tobramycin, spectinomycin, neomycin,

kanamycin, or amikacin. I will agree to notify Dr. ________________ if I have any of these

conditions or if I am taking these medications.

BOTOX® Cosmetic is approved by the FDA to improve the appearance of the vertical

lines between the brows. Injections in other areas to improve the appearance of facial

lines and for facial shaping have been well documented in the literature, although

they are considered “off label” uses. The results of BOTOX® Cosmetic are usually

dramatic, although the practice of medicine is not an exact science and no

guarantees can be or have been made concerning expected results .

Patient’s Initials _______________

The BOTOX® Cosmetic solution is injected with a tiny needle into the skin and muscle.

You should see the benefits develop over the next two to seven days. A decreased

appearance of frowning, creasing, lines, and/or a change in specific facial grimacing

will be the result of this treatment.

Patient’s Initials _______________

The most common side effects are headache, respiratory infection, flu syndrome,

temporary eyelid droop, and nausea. BOTOX® Cosmetic should not be used if there is

an infection at the injection site. Additionally, slight temporary bruising may occur at

the injection site. I have been advised of the risks involved in such treatment, the

expected benefits of such treatment, and alternative treatments.

Patient’s Initials _______________

I understand that the results are temporary and repeat treatments are needed to

maintain the desired results.

Patient’s Initials _______________

I agree that this constitutes full disclosure and that it supersedes any previous verbal

or written disclosures.

I certify that I have read and fully understand the above paragraphs and that I have had

sufficient opportunity for discussion and to ask questions. I consent to this BOTOX®

Cosmetic treatment today and for all subsequent treatments.

Patient’s Signature _______________________________________ Date ________________

Physician Signature ____________________________________ Date ________________

Botox Consent Form - Doctors Of Internal Medicine

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