Botulinum Toxin Treatment Consent Form

Purpose of the Consent:
To provide written information regarding the risks, benefits, and alternatives of the treatment this consent is written. It is important that the patient should fully understand the treatment priorly. Before signing the consent, the patient should ask any of the questions regarding the treatment, botulinum toxin and procedures to their doctor or healthcare professional.
The Treatment Information:
Botulinum toxin which can be branded as Azzalure, Botox, or Bocouture is a neurotoxin produced by the bacterium Clostridium This toxin may result in relaxation of the muscles especially on the face and neck that may cause wrinkles associated with facial expressions or facial pain. Botulinum toxin treatment might make your facial expression lines or wrinkles less noticeable or totally disappear. The most frequently treated areas are a glabellar area of frown lines located between the eyes, crow’s feet (lateral areas of the eyes), forehead wrinkles, radial lip lines (smokers lines), head and neck muscles. Injection of Botox into the muscles is not painful since it happens with a very thin needle, but some patients might sense a little burning pain at the moment of injection. The total procedure takes approximately 15 minutes and after three months, patients can see the results. If the treatment repeats, the results may last longer.
Risks and Side Effects:
The possible side effects are listed below. However, the patients should be aware that there may be unique effects to certain people that are not known right now.
• Transient headache, swelling, bruising, bleeding, pain, twitching, itching, puffiness around the eyes or numbness, any other sensation differences.
• Rarely possible: Allergy including anaphylaxis
• Asymmetry
• Temporary drooping of facial features
• Dry eyes
• Double or blurred vision
Limitations and Alternatives:
Time to time, there are cases that the treatment could not be successful or wears off quickly.
I agree to the following:
I have been given enough information about the treatment I am to receive and informed about the procedure. I got the detailed explanation of the procedure I am to undergo. I understand the aims and objectives of the treatment completely. They have given me the opportunity to ask all remaining questions I may have about the treatment, and I answered them to the best of their ability. Having considered all aspects, I have decided to have this treatment of my own accord with sole intention the anticipated benefit from the same, provided by my therapist performing the treatment procedure. I understand that I will not be able to sue my therapist in case of any complications or be entitled to a refund if I am not happy with my procedure.The alternative treatments including topical creams, chemical peels, laser, surgical denervation, forehead/brow lift, facelift, or hyaluronic acid are considered by me and I elected that Botulinum toxin is the best one for me.I have given enough time to consider this treatment and I have answered a detailed medical history form above to the best of my knowledge.I agree to follow advices given to me after treatment.ACCORDING TO THE INFORMATION ABOVE, I AM GIVING CONSENT TO RECEIVE THE TREATMENT BY MY THERAPIST.
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