Botox Therapy Consent Form printable pdf download

Botox Therapy Consent Form

Please initial each section to indicate that you understand each topic. Do not initial if you desire

more information.

Proposed Treatment

Injection of a very small amount of Botox®, a purified toxin produced by the bacterium clostridium botulinum,

into the specific muscle causes weakness or paralysis of that muscle. This results in relaxation of the muscle and

improvement of the lines or wrinkles that the muscle action has formed.

Initials: _____

Anticipated Benefit

Response usually is seen 2-10 days after injection. Typically, the muscle action (and wrinkles) will return in 3-5

months. At this point, a repeat treatment will relax the muscle and soften the lines again. Initials: _____

I understand that several sessions may be needed to complete the injection series. I understand that there is a

separate charge for any subsequent treatment. Initials: _____

Risks and Complications

Possible side effects include: transient headache, swelling, bruising, pain during injection, twitching, itching,

numbness, asymmetry (unevenness), temporary drooping of eyelids or eyebrows. These side effects are rare, but

have been reported. In a very small number of individuals, the injection does not work as satisfactorily or for as

long as usual.

Known significant risks have been disclosed, yet the theoretical risk of unknown complications does exist.

Initials: _____

Bruising may occur after Botox injections. Substances that increase the risk of bruising include Vitamin E, aspirin,

Motrin and other non-steroidal anti-inflammatory drugs. I understand that if I have taken any of the above within

the past 7 days, I have an increased risk of bruising. Bruising is also a significant risk with the use of blood thinning

medications such as Coumadin. I understand that if I am taking a blood thinning medication, this treatment may

result in significant bruising and may not be recommended. Initials: _____

I understand that there may be a higher possibility of side effects if I do not follow certain instructions and will

adhere to these instructions for at least 4 hours from the time of treatment. Initials: _____

Pregnancy & Neurological Disease

I understand that there are certain conditions where Botox® treatments are not recommended.

These include:

• Neurological disease, such as myasthenia gravis

• Pregnancy or breastfeeding

None of the conditions above apply to me. Initials: _____

7942.BotoxConsent

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Botox Therapy Consent Form