As Botox is not an exact science, there might be an uneven appearance of the face with some muscles more affected by the Botox than others. In most cases this uneven appearance can be corrected by injecting Botox in the same or nearby muscles. However, in some cases this uneven appearance can persist for several weeks or months. This list is not meant to be inclusive of all possible risks associated with Botox as there are both known and unknown side effects associated with any medication or procedure. Botox should not be administered to a pregnant or nursing woman. Additionally, The number of units injected is an estimate of the amount of Botox required to paralyze the muscles. I understand there is no guarantee of results of any treatment. I understand the regular charge applies to all subsequent treatments.
I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I further agree in the event of non-payment, to bear the cost of collection, and/or Court cost and reasonable legal fees, should this be required. By signing below, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks. I hereby give consent to perform this and all subsequent Botox treatments with the above understood. I hereby release the doctor, the person injecting the Botox and the facility from liability associated with this procedure.