Neurotoxin Injections Consent
Neuromodulators (Botox® & Xeomin) are FDA approved treatment for the temporary reduction of moderate to severe forehead lines and wrinkles, frown lines and crow’s feet. It is accomplished by injecting small amounts of solution in the area of the wrinkles. Neuromodulators work by temporarily relaxing the facial muscles that are responsible for producing the wrinkling of the facial skin, thus producing the appearance of smoother, flatter skin.
It is recommended that you not take aspirin, non-steroidal anti-inflammatory medication, or any blood anti-coagulants before this procedure. These medications may increase the risk of bruising. If you are able to stop these medications, you should do so one 1 week before the procedure.
Patients with certain medical conditions may NOT have this procedure done. These include those with any type of facial paralysis such as Bell’s palsy, Guillain-Barre Syndrome and Myasthenia Gravis. Patients who are pregnant or breastfeeding should not use neuromodulators.
The effects of the procedure typically last about 3-5 months and are rated by the manufacturers to last up to 12 weeks. Be advised that it is possible for a patient to experience some adjacent facial muscle relaxation in areas other than the intended target muscle. Most common is the effect of ptosis, or eyelid droop. This condition occurs in less than 3% of injections. It is temporary and will usually resolve before the product wears off. The main side effects after injections are pain from injection and bruising, which are usually minimal and temporary. Localized hypersensitivity to the saline may also occur temporarily.
By signing this consent, you agree that you have read information regarding neuromodulator injections, understand that the use of aspirin, non-steroidal anti-inflammatory drugs or blood thinning medication within the last 3 days, may increase the risk of post-injection bruising. You understand the procedure and its side effects. The personnel at Organica Aesthetics have been provided with a thorough and truthful medical history. Additional injections may be necessary, for which Organica Aesthetics will charge as additional units (at the per unit price you originally paid), if optimal effect is not reached in 10 to 14 days. The products have only a temporary effect that lasts approximately 3-5 months and you will need to repeat injections 3-5 times a year to continue the effect.
Risks, hazards and costs of care or expense associated with or which may arise from such treatment, hereby releasing the injector, medical director, staff, sponsoring facility and its affiliates and employees from any liability from said treatment except where such risks and hazards are the proximate result of gross negligence. This constitutes the full disclosure and supersedes any previous verbal or written disclosures, advertising or marketing materials prepared by us or other.