I am giving consent to be injected with Botox, Xeomin, or Dysport in areas of the face, neck, and/or axilla. Botox, Xeomin, and/or Dysport have FDA indications in the cosmetic treatment of glabella and/or lateral canthal lines for temporary wrinkle reduction. All are prescription medications (botulinum toxin type A) that are used on and off label cosmetically in the reduction of wrinkles. Botox also has a FDA therapeutic indication for axillary hyperhidrosis.
Although these medications are botulinum toxin type A, they are not interchangeable and the dosages are not equivalent. I understand that some treatment sites or all of my treatment sites may be off label Botox, Xeomin, and/or Dysport when injected into targeted muscle groups stop the release of acetylcholine therefore reducing muscle movement of the area and decreasing wrinkles caused by this movement. The immobilization of the muscles injected is temporary, lasting for approximately 3-4 months when injected cosmetically and 6-7 months when injected therapeutically for hyperhidrosis, reinjection will be needed at that time to maintain or achieve satisfactory results. It has been explained to me that other temporary and more permanent results are possible.
Botox, Xeomin, and/or Dysport have possible side effects which include, but are not limited to, infection at the site of injection, red or pink bumps at the site of injection lasting hours or days, tension headache for one up to several days, pain at injection site, bruising, flu like symptoms, fever, nausea, respiratory compromise and depression, weakness or adjacent muscles, facial asymmetry, limb weakness, difficulty swallowing, difficulty articulating words, eyelid droop, brow droop, blurred vision, double vision, decreased eye sight, wheezing, loss of bladder control, corneal abrasion, dry eye syndrome, spread of toxin effects, soft tissue swelling, and allergic reactions. This is not an all-inclusive list of side effects. I understand that these symptoms have been reported within hours to weeks 3 after injection.
I am not pregnant or nursing. I am a minimum of 18 years old. I have not been diagnosed with any neuromuscular junction disorders or peripheral neuropathic diseases including but not limited to amyotrophic lateral sclerosis, myasthenia gravis, and Lambert-Eaton syndrome. These neuropathic disorders increase the risk for spread of toxin effect. I do not have a cow's milk protein allergy. I have been given the opportunity to have my questions answered after reading and acknowledging The Patient Medication Guide.
I understand that results vary depending on the strength of the muscle injected and surrounding muscles, the depth of the wrinkle, the quality of the skin, underlying tissue, elasticity, the amount of Botox, Xeomin, and/or Dysport injected, and the time between treatments. I understand that there is no guarantee of treatment results and longevity. I understand that if a refinement treatment is needed, I will have treatment 10-16 days after initial treatment. Any additional units used will be charged at regular price per units that I receive.
I will relay to my provider any botulinum toxin products I have received in the last four months. I have not received any antibiotics by injection. I am not currently taking any muscle relaxants. I understand that vitamin E, aspirin, NSAIDS, ginkgo, fish oil, and alcohol consumption may have bruising effects post treatment.
I agree to abide by my providers post care instructions for best results. If I experience any loss of strength or general muscle weakness, I will contact my provider or the nearest emergency center.
Hyaluronic gel is a colorless gel implant that consists of crossed linked hyaluronic acid (HA) produced by Streptococcus equi bacteria. Concentrations and molecular weight of HA vary between products. HA (above mentioned) has FDA approved indications that vary between products that are inclusive of injection into the mid to deep dermis, subcutaneous, and periosteal plane. Approved injection sites are nasolabial folds, oral commissures, chin lines, lips, lip lines, marionette lines, and cheek augmentation. Off label sites where HA can be injected include temples, tear troughs, nose, brows, ears, hands, and facial scars. Hyaluronic acid is used cosmetically to add volume, fill in wrinkles, lift, and contour. Lidocaine may or may not be compounded in the HA product being injected. I affirm I am not allergic to lidocaine.
Any transcutaneous procedure carries the risk of infection. Standard protocol will be used to ensure aseptic technique and procedure. These products are sterile packaged for single patient, single session injection. No part of the product will be saved for later date. If any chemical peel, laser treatment or other procedure based on active dermal response is considered after treatment, there is a possible risk of inducing an inflammatory reaction at the implant site. Inflammatory reaction can also occur if the product is injected before the skin has completely healed after any such procedure.
I affirm that I am not pregnant, trying to become pregnant, or breastfeeding. I am of 18 years of age. I am not on any immunosuppressive therapy and have not had any active infection in the area where I will be injected. I will tell my provider if I am herpes simplex type 1 positive and if I have a history of keloid scarring. I am aware that aspirin, non-steroidal anti-inflammatories, anti-coagulants, vitamin E, fish oil, and gingko within 7-10 days of an injection contribute to bruising, in addition to alcohol consumption within 48 hours. Bruising prolongs the recovery period post injection. The most common side effects of dermal filler injections include tenderness, redness, swelling, firmness, lumps/bumps, discoloration, and bruising. Other adverse reactions reported post market can include but are not limited to; inflammation, migration, allergic reaction, blister, infection, nodules, late onset granulomas, skin rash, bleeding, necrosis at the injection site, abscess, headache, itching, herpes simplex, angioedema, dermatitis, flu like symptoms, scar, blanching, vision changes, induration, erythema, pain, and blindness.
Other options for reducing wrinkles or adding volume may include home care products, chemical peels, laser treatments, and/or surgery. I am aware that every presentation requires a unique combination of product, amount of product, placement, and other contributing factors to meet desirable outcome. The amount of correction is based on the size of the deficit and the amount of the product injected. Products may last from up to 6 months to 2 years. I realize this is in no certain term a guarantee of the longevity of the product or my satisfaction with the procedure. No refunds will be given for treatments received. I will make every effort to return in 2 weeks for a follow up if recommended. Over time, the natural metabolic process will disintegrate the HA.
It is recommended to avoid strenuous exercise, sun, heat, and alcoholic beverages for 24 hours. Exposure to the above will increase recovery times resulting in extended redness, bruising, swelling, and/or itching.