Botox Consent Botox Consent Form Name* First Last Phone*Today's Date* Date Format: MM slash DD slash YYYY Email LocationLocationPitt MeadowsPort MoodyBeing fully informed about your condition and treatment will help you to make a decision about BOTOX@ Cosmetic treatment. This disclosure is an effort to provide you with that information. BOTOX@ Cosmetic solution is injected with a very small needle into the facial muscle; you should see the benefits develop over the next two to seven days. A decreased appearance of frowning or creasing of facial lines will be the expected result of the treatment. Possible side effects are headache, respiratory infection, flu syndrome, temporary eyelid droop, and nausea - these are rarely experienced. however, slight temporary bruising may-occur at the injection site. BOTOX@ Cosmetic will not be used if there is an infection at the injection site. I have requested that Dr. attempt to improve my facial lines with BOTOX@ Cosmetic. This is the Allergan trademark for Botulinum Toxin Type A. These injections have been used for more than a decade to improve spasm of the muscles around the eye, to correct double vision due to muscle imbalance, as well as for other neurological disorders. BOTOX@ Cosmetic is now approved by the FDA to improve the appearance of the vertical lines between the brows. A few injections of BOTOX@ Cosmetic relax overactive muscles and soften those vertical lines. Injections have been reported to improve appearance of facial lines in other areas, but the FDA has not approved those uses as yet. The results of BOTOX@ Cosmetic are usually dramatic, but because of individual variations in response no guarantees can be or have been made concerning expected results. I understand that results are temporary and that several sessions may be needed to achieve optimum results. Agreement* Yes I agree I agree that this constitutes full disclosure, and that is supersedes any pervious verbal or written disclosure of information. I certify that I read and fully understand the above information and that I have had sufficient opportunity for discussion and to ask questions. I consent to BOTOX, Cosmetic treatment today, and for all subsequent sessions which I and my doctor agree are necessary. ELECTRONIC CONSENT*AGREEDISAGREEELECTRONIC CONSENT: Please select your choice below. Clicking on the "agree" button below indicates that: • I have read and fully understand this agreement and all information detailed aboveSignature*CAPTCHA
