BOTOX/DYSPORT INFORMED CONSENT

I, understand that I will be injected with Botulinum A Toxin. (Botox), Dysport.

The possible side effects of Botox/Dysport include, but are not limited to:

Please Initial

- I understand there is a risk of swelling, rash, headache, local numbness, pain at the injection site, bruising, respiratory problems, and allergic reaction.

- Infections can occur, which in most cases are easily treatable but in rare cases a permanent scarring in the area can occur.

- Most people have lightly swollen pinkish bumps where the injections went in, for a couple of hours or even several days.

- Headache is possible following treatment with Botox/Dysport, for the first day. In a very small percentage of patients these headaches can persist for several days or weeks.

- Local numbness, rash, pain at the injection site, flu like symptoms with mild fever, back pain may occur.

- Respiratory problems such as bronchitis or sinusitis, nausea, dizziness, and tightness or irritation of the skin may occur.

- Bruising is possible anytime you inject a needle into the skin. This bruising can last for several hours, days, weeks, months and in rare cases the effect of bruising could be permanent.

- While local weakness of the injected muscles is representative of the expected pharmacological action of Botox/Dysport, weakness of adjacent muscles may occur as a result of the spread of the toxin.

- I understand more than one injection may be needed to achieve a satisfactory result.

- I am aware of another risk when injecting Botox/Dysport around the eyes included corneal exposure because people may not be able to blink the eyelids as often as they should to protect the eye. This inability to protect the eye has been associated with damage to the eye as impaired vision, or double vision, which is usually temporary.

- The number of units injected is an estimate of the amount of Botox/Dysport 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 have read and understand the Pre and Post-Treatment Instructions. I agree to follow these instructions carefully. I understand that compliance with recommended pre and post procedure guidelines are crucial for healing, prevention of side effects and complications as listed above.

- There are NO REFUNDS given for any treatment rendered regardless of results.

- I am not pregnant or trying to become pregnant nor am I nursing at this time. I understand that photos may be taken before and/or after the procedure for my file to help document my progress. I allow their use for any scientific, educational or research purposes deemed appropriate as long as my name and identity are protected.

I release staff and specific technicians from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns. I agree this procedure is entirely cosmetic and is of my own free will and I will not seek legal restitution from the physician and affiliates.

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/Dysport treatments with the above understood. I hereby release the doctor, the person injecting the Botox and the facility from liability associated with this procedure.

Note: All prices are subject to change without prior notice

Client’s Name:

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