Botulinum Toxin Consent

BTX Consent

DD slash MM slash YYYY
DD dash MM dash YYYY
Botulinum Toxin may be branded as Dysport, Botox or Xeomin. It is a purified protein produced by the bacterium clostridium botulinum. The product causes muscle relaxation and suppresses sweating for 2- 6 months on average (with wide variation between individuals) by temporarily disrupting nerve activity to muscles and sweat glands.(Required)
Possible side effects include, but may not be limited to: - bruising, redness, swelling, pain, allergy, infection, droop of an eyebrow or eyelid or weakness in an unintended facial muscle, dry eyes, double or blurred vision or a transient headache.(Required)
I have disclosed my medical and drug history to my clinician and am aware that many medications increase the risk of bruising and include but are not limited to: Fish oil, Vitamin E, aspirin, Motrin, clopidogrel, warfarin and others.(Required)
Occasionally the treatment wears off very quickly or does not work at all. Botulinum Toxin is best at treating dynamic facial lines; those caused by facial muscle activity, lines present at rest may or may not improve.(Required)
A follow up review 2 weeks following your first treatment is recommended. I understand that any adjustments needed 3 weeks after my treatment, will likely incur a charge. I understand that with all treatments the actual degree of improvement cannot be predicted or guaranteed. The outcomes subjective nature means dissatisfaction is a possible outcome regardless of effectiveness of treatment. I understand that the effect of all treatments may gradually wear off and additional treatments will be necessary to maintain the desired effect.(Required)
By consenting to this treatment you agree that you have read this form carefully and considered the side effects, risks and uncertainty of the outcome and decided the treatment is still in your be treatments and your best interests. You have discussed all the details of the treatment plan, past treatments and your medical history with your clinician and shared all the information your clinician may need to plan a treatment. You agree that the balance of the benefits and risks to your overall favour the use of botulinum toxin. I understand that no refunds are issued due to any of the above occurring. I understand photographs are taken and stored as part of my medical record.(Required)