1. I attest that I am not allergic to eggs or to neurotoxin.
2. I voluntarily request that the Practitioner administer neurotoxin, either the drug Botulinum Toxin Type A (Botox) or abobotulinumtoxinA (Dysport) to me. I understand the intended use and benefit of neurotoxin is to improve the appearance of wrinkles around the eyes (crow’s feet), moderate to severe frown lines between the eyebrows (glabellar lines).
3. I have been advised and I understand that research has proven neurotoxin works best on those wrinkles known as “hyperkinetic wrinkles” (wrinkles in motion). These hyperkinetic muscles contract during facial expressions such as squinting or frowning. Neurotoxin works by blocking the signal from crossing the “neuromuscular junction” and allows the muscle to relax and helps eliminate the wrinkles that lie above. I have been advised and I understand that: Neurotoxin can be injected in small amounts into the affected muscle(s) and that no sedation is required for a neurotoxin injection. I understand that the FDA has approved neurotoxin for patients under the age of 65.
4. I understand that the benefit of neurotoxin develops over a two-week period and lasts approximately 3-6 months. The treatment is temporary. I understand and acknowledge that no guarantee has been given as to the results of a neurotoxin treatment. It has been explained to me that this procedure may fail to reduce wrinkles completely and that multiple treatments are required to obtain results.
5. I understand that the alternative of not using neurotoxin is to use prescribed creams (Retin A or a chemical peel), facial exercises, or treatments (laser resurfacing) as discussed with me by my physician or associated staff.
6. I understand that the risks associated with the use of neurotoxin include but are not limited to: swelling, bruising, rash, local numbness, pain at the injection site, headache, drooping eyes, loss of facial expression, drooling, burning sensation and/or minimal pain during the injection, paralysis in one or more extra-ocular muscles (eyes) causing double vision, facial asymmetry, permanent loss of muscle tone with repeated injections, development of antibodies, and allergic reaction. Increased bruising and bleeding are common in patients taking medications that reduce blood clotting such as aspirin, ibuprofen, Naprosyn, Motrin, Advil, and Aleve. We recommend stopping such medications 10-14 days prior to the procedure.
7. I understand that neurotoxin should not be used in people who have myasthenia gravis or any other neurological disorder, or on pregnant or lactating women.
8. I understand that infections can occur which in most cases are easily treatable but in rare cases a permanent scarring in the area can occur.
9. I understand that I may have lightly swollen pinkish bumps at the injection sites, for a couple of hours or even several days.
10. Photographs may be taken before and after treatments to monitor progression, which I consent to.
Because of my particular medical condition, the following additional risks have also been explained to me (next field):