BOTOX® Injection Consent
INJECTION CONSENT FOR: BOTOX/ DYSPORT/ JEUVEAU/ XEOMIN
If you have any questions, please ask your doctor BEFORE signing.
BOTOX/DYSPORT/JEUVEAU/XEOMIN is a substance originally used for treating muscular disorders of the eye, but has also been found useful as a reversible muscle relaxant. As such, it may be used to temporarily relax certain facial muscles, thus having a cosmetic effect by smoothing certain facial wrinkles (“Crow’s feet” and other lines of expression).
The effect of BOTOX/DYSPORT/JEUVEAU/XEOMIN begins in a few days and lasts for up to 3 months, at which time retreatment is necessary to gain a similar muscle relaxant effect. Occasionally, “touch-up” injections may be required for full effect. Studies have shown that, in rare cases, a patient may develop antibodies to BOTOX/DYSPORT/JEUVEAU/XEOMIN in as few as three doses, thereby reducing its effectiveness. Thus, Botox may occasionally not have the planned effect or the results may not be as anticipated.
Proposed treatment: Injection of BOTOX/DYSPORT/JEUVEAU/XEOMIN in the following facial areas:
You have the right to be informed about the proposed treatment so that you may make the decision whether or not to undergo the procedure after knowing the risks and complications involved. This disclosure is not meant to create anxiety, but is simply an effort to better inform you so that you may give or withhold your consent.
BOTOX/DYSPORT/JEUVEAU/XEOMIN injections may include the following risks and complications and others:
1.Allergic reactions, including rash, itching, local swelling, or more severe reactions.
2.BOTOX/DYSPORT/JEUVEAU/XEOMIN contains albumin from human blood, to which certain individuals are allergic. Ifyou have had adverse reactions to certain immunizations or are allergic to eggs, you should not use Botox.
3.The effects of BOTOX/DYSPORT/JEUVEAU/XEOMIN are potentiated (increased) when patients are taking certainantibiotics (aminoglycoside derivatives) and other drugs that interfere with neuromuscular transmission. Be sure toadvise your doctor of all medications you are taking or have recently taken.
4.Because BOTOX/DYSPORT/JEUVEAU/XEOMIN contains human albumin, there is a remote chance of transmission ofserious viral diseases. This complication has never been identified, but it is possible.
5.Bruising may be possible, especially if BOTOX/DYSPORT/JEUVEAU/XEOMIN is used around the eye area. Typically,these discolored areas disappear with time.
6.If used around the eye, BOTOX/DYSPORT/JEUVEAU/XEOMIN may cause difficulty in closing eyelids tightly. The resultmay be corneal exposure with resultant drying, potential ulceration and visual complications. The affected eyelid maydroop. Protective patching and/or medication may be required until this complication has passed.
7.The safety of BOTOX/DYSPORT/JEUVEAU/XEOMIN in pregnant women, nursing mothers, or anyone under the age of21 has not been established. Please advise your doctor if there is any chance you might be pregnant.
8.Off-Label FDA: There are many devices, medications, injectable fillers and botulinum toxins that are approved forspecific use by the FDA, but this proposed use is “Off-Label”, that is not specifically approved by the FDA. It is importantthat you understand this proposed use is not experimental and your physician believe it to be safe and effective.Examples of commonly accepted “Off-Label” use of drugs or devices include the use of aspirin for prevention of heartdisease, retinoids for skin care, and injection of botulinum toxin for wrinkles around the eyes.
I have fully and truthfully informed my doctor of my past medical and social history, including drug and alcohol use, recognizing that withholding information may jeopardize the planned outcome of this treatment.
I agree to cooperate fully with my doctor’s recommendations while under treatment, realizing that any lack of cooperation can result in a less-than-optimal result.
If any unforeseen condition should arise during this procedure calling for additional or different procedures from those planned, I authorize my doctor to use professional judgment to provide the appropriate care to complete the procedure.
I understand this is an elective procedure and have not been given any warranty or guarantee as to the result of the proposed procedure.
CONSENT
I understand that my doctor can’t promise that everything will be perfect. I understand the reasons for the proposed treatment and potential benefits to me; it has been explained to me what alternatives there are, if any, to this treatment. I have given a complete and truthful medical history, including all medicines, drug use, pregnancy, etc. I certify that I speak, read and write English. All of my questions have been answered before signing this form and I am willing to undergo this elective treatment.