Skin Rn Botox Cosmetic Informed Consent Form (Page 2 of 2) in pdf

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.

As Botox is not an exact science, there might be an uneven appearance of the face with some muscles

more affected by the Botox than others. In most cases this unevèn appearance can be corrected by

injecting Botox in the same or nearby muscles.

I have thoroughly read and understand this agreement and informed consent. I DO NOT have any

medical conditions or any contraindications that would prevent me from of being a candidate for

Botox. All of my questions have been addressed and answered to my satisfaction. I consent to the

terms of this agreement and I hereby give permission to Sheryl Bridgewater, RN with SKIN RN,

LLC to inject BOTOX COSMETIC into specific areas I have requested.

I certify that I am a competent adult of at least 18 years of age. This consent form is freely and

Voluntarily executed and shall be binding upon my spouse, relatives, legal representatives,

Heirs, administrators, successors and assigns.

By signing below, I acknowledge that I have read the foregoing informed consent and agree to the

treatment with its associated risks. I hereby give consent to perform this and all subsequent Botox

treatments with the above understood. I hereby release SKIN RN, LLC the healthcare provider injecting

the Botox and the medical director from liability associated with this procedure.

Patient signature___________________________________________ Date_____________

Patient printed name_________________________________________________________

Witness __________________________________________________________________

For Future Visits

Initials_________ Date_______

Skin Rn Botox Cosmetic Informed Consent Form Page 2