Botulinum Toxin Treatment Consent Form

Botulinum Toxin Treatment Consent
1. I am aware that when small amounts of purified botulinum toxin (“Botox Cosmetic”) are injected into a muscle, the muscle is weakened. This effect appears in 12 - 14 days and usually lasts approximately 3 - 4 months.
2. I understand that this treatment will reduce or eliminate my ability to “frown” and/or produce “crow’s feet” or forehead “worry lines” while the injection is effective, but that this will reverse itself after a period of months at which time re-treatment is appropriate.
3. I understand that I must stay in the erect position and may not manipulate the area of injection or participate in strenuous activity for 4 hours after treatment. I also understand that I must exercise the treated muscles for 2 hours after treatment.
4. I agree to return for a follow up visit 10 – 14 days from my treatment.
5. I have been made aware of alternative methods of treatment.
6. I am aware that Botox Cosmetic treatment of forehead lines can cause a minor temporary droop of one eyelid in approximately 2% of injections. This usually lasts 2 – 3 weeks. Occasional temporary numbness of the forehead, flu-like symptoms, minor bruising, swelling or temporary headache may occur.
7. I am aware that individual patients respond differently to Botox Cosmetic and that exact results cannot be guaranteed. Depending on musculature, some patients will require more units, while others will require fewer units to achieve the same results.
8. To my knowledge, I am not pregnant and do not have any significant neuralgic or muscular disease.
9. I have had the opportunity to ask questions, and they have been answered to my satisfaction.
10. I consent to photographs being taken to evaluate treatment effectiveness, for medical education, training, professional publications, or sales purposes. No photographs revealing my identity will be used without my written consent. If my identity is not revealed, these photographs may be used without my permission.
11. I agree to being governed by the laws and statutes of Alberta, Canada.
12. I accept the risks and complications of this procedure and I consent to the injection of Botox Cosmetic to my face and neck.
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