Skin Rn Botox Cosmetic Informed Consent Form printable pdf download

SKIN RN

BOTOX COSMETIC INFORMED CONSENT FORM

I _______________________________________________,, understand that I will be injected

with Botulinum a Toxin (Botox). Possible Areas of Treatment include: Glabella (between the eyes)

crow’s feet (periorbital lines), (frontalis) forehead, vertical upper lip (perioral lines), and jaw and

neck areas.

Description: BOTOX COSMETIC (Botulinum Toxin Type A) Purified Neurotoxin Complex is a

sterile, vacuum-dried purified botulinum toxin type A, produced from fermentation of Hall strain

Clostridium botulinum type A grown in a medium containing casein hydrolysate, glucose and

yeast extract. Botox is FDA approved for the glabella area.

Cosmetic Indications and Usage: BOTOX COSMETIC is indicated for the temporary improvement

in the appearance of moderate to severe glabellar lines associated with corrugator and/or

procerus muscle activity in adult patients less than 65 years of age.

Contraìndications: Patients with muscular or neuromuscular disorders such as

Myasthenia Gravis, Eaton-Lambert Syndrome, ALS should not be treated with BOTOX as

well as women who are pregnant, actively breastfeeding or have known Keloid scarring.

Botox Cosmetic is contraindicated in the presence of infection at the proposed injection

site(s) and in individuals with known hypersensitivity to any ingredient in the formulation.

Botox should not be administered to a pregnant or nursing woman.

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

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

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

2. Infection: infections can occur while in most cases are easily treatable but in rare cases a

permanet 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.

Skin Rn Botox Cosmetic Informed Consent Form