INFORMED CONSENT FOR BOTULINUM TOXIN (BOTOX®) TREATMENT
Please read this document carefully. If you have any questions regarding the procedure, please consult the medical provider or the Nurse before signing this consent form.
TREATMENT OVERVIEW
Botulinum toxin (Botox®) is a neurotoxin derived from the bacterium Clostridium botulinum. It temporarily relaxes facial and neck muscles responsible for wrinkles caused by facial expressions. As a result, fine lines and wrinkles become less noticeable and may even disappear. The effects typically last up to four months, and with repeated treatments, the duration of results may extend.
Commonly treated areas include:
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Frown lines (between the eyebrows)
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Crow’s feet (outer corners of the eyes)
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Forehead wrinkles
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Neck bands (platysmal bands)
Additionally, botulinum toxin (Botox®) may be used for medical conditions such as migraines, excessive sweating (hyperhidrosis), and facial palsy.
The procedure is quick, typically lasting 15-20 minutes. It involves a series of small injections using a fine needle to target specific areas. Some patients may experience a mild burning sensation during injection.
RISKS AND POSSIBLE COMPLICATIONS
While generally safe, no procedure is completely risk-free. Rare but potential risks include:
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Temporary discomfort, swelling, redness, or bruising at the injection site
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Double vision
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Weakened tear ducts
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Post-treatment bacterial or fungal infection
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Allergic reactions
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Minor temporary drooping of the eyelids
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Occasional numbness of the forehead for up to 2-3 weeks
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Temporary headache or flu-like symptoms
PREGNANCY, ALLERGIES, & NEUROLOGIC CONDITIONS
Botulinum toxin treatment is not performed on individuals who:
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Are pregnant or breastfeeding
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Have a history of significant allergic reactions
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Have neurological conditions such as Myasthenia Gravis, Multiple Sclerosis, Lambert-Eaton Syndrome, Amyotrophic Lateral Sclerosis (ALS), or Parkinson’s disease
PAYMENT POLICY
I understand that this is an elective procedure and that full payment is required at the time of treatment.
PATIENT CONSENT
I acknowledge that the procedure has been explained to me, and I have had the opportunity to ask questions. I understand the risks and potential complications associated with the treatment.
I confirm that I am not currently pregnant, trying to conceive, or breastfeeding. I do not have any significant neurological disorders or allergies to botulinum toxin ingredients or human albumin.
I agree to inform the medical provider, the nursing staff, or the reception team of any changes in my medical history before receiving further treatments.
I voluntarily consent to receive botulinum toxin (Botox®) treatment.
