This is an informed consent document that has been prepared to help educate you about Botox® Cosmetic, Xeomin® and Dysport™ injections, their risks, and alternative treatments(s) so that you can make an educated decision on whether this elective treatment is right for you.
Please discuss any questions you may have with your provider. Once you have read , understand this information, and had any questions answered to your satisfaction, please sign and date this consent. The consent will stay in effect for the duration of your treatments.
Injections of a small amount of Botox® Cosmetic, Xeomin® or Dysport™, a purified protein, into specific muscles of face and neck, relax those muscles temporarily so that they don’t cause “dynamic” wrinkles of the skin in those areas. Weakening of the injected muscles begins to be apparent after 2-3 days with the peak effect being reached after 7-14 days. Results can last 3-6 months. The procedure can be repeated when dynamic wrinkles reappear. Repeated treatments, before the effects fully wear off, will cause the affected muscles to decrease in size and the effect of regular injections to last slightly longer.
Each time you request Botox® Cosmetic, Xeomin® or Dysport™, you will be examined by your Physician or Registered Nurse to determine which dynamic wrinkles of the face and/or neck are likely to respond to Botox® Cosmetic, Xeomin® and Dysport™ and which product may be recommended for you at that time. Once a treatment plan is agreed on, digital pictures of your face at rest and when wrinkling are obtained, cleansing of the treatment areas is done and topical anesthetic is applied. Just before the injections, ice packs are applied to minimize bruising and increase injection comfort. A diagram is made of the injection locations and dosages to continue or improve the results of your next injection session. Please keep track of your results, what you liked best and where you wanted more, so that we can customize your treatment every time, if needed.
You will be asked NOT to lay down for 3 to 4 hours after your injections and NOT to rub the areas of injection so that the effects don’t migrate. You will be asked to make facial expressions in the area of the injections to help the Botox® Cosmetic, Xeomin® or Dysport™ attain the greatest effect.
Botox® Cosmetic, Xeomin® and Dysport™ are NOT recommended for patients with neurologic diseases including Myasthenia Gravis, Eaton-Lambert Syndrome and Lou Gehrig’s disease. They are also NOT recommended for injection during pregnancy or breast-feeding.
Alternative forms of non-surgical and surgical management for the appearance of wrinkles and lines in the skin include laser ablation, chemical peels, dermal fillers, minimally invasive procedures and face lifts. Alternative forms of treatment are all associated with certain risks, recovery and success.
Fillers generally work well with Botox® Cosmetic, Xeomin® and Dysport™. The fillers help relieve the “static” wrinkles present when the face is at rest. Each product seems to help the other last longer and gives a more global rejuvenation to the treated area.
PLEASE INITIAL YOUR UNDERSTANDING OF EACH PARAGRAPH
An individual’s choice to undergo a procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience these complications, you should be aware of them and discuss each of them with your injector to make sure you understand the risks, potential complications, and consequences.
It is possible, though unusual, to experience localized bleeding during or after the procedure at the site(s) of injection. ****Do not take any Aspirin, anti-inflammatory medications or blood thinners like Coumadin, Vitamin E or Fish Oil for ten days prior to your Botox® Cosmetic, Xeomin® or Dysport™ injection appointment.
Infection is unusual. Should an infection occur, additional treatment including antibiotics might be necessary.
You may be disappointed with the results of the procedure or its duration of action. Sometimes the results are uneven. This is generally temporary and improves with time.
In rare cases, local allergies to Botulinum toxin A preparations have been reported. Some patients get swelling under their eyes, headaches or cold symptoms after injections. These symptoms are treated appropriately and resolve. They do not always recur with future injection sessions. Systemic reactions (very rare), may result from any medication or substance used during the procedure. Allergic reactions may require additional treatment.
Following this procedure, it is not uncommon to bruise at the injection site. Bruising usually resolves in 3-7 days.
This is a rare, transient complication occurring in 1-2% of patients. The incidence can be minimized by not lying down for 3 to 4 hours after injections. Eyelid drooping usually resolves within several weeks but may take longer. It is sometimes improved with Iopidine (prescription) eye drops.
Should complications occur, other treatments may be necessary. Even though risks and complications occur infrequently, the risks cited are the ones that are particularly associated with injections.
I authorize the taking of clinical photographs for the medical record and education. If used for advertising, pictures will be cropped, blacked out and all personal data deleted to assure my identify will be protected.
Although good results are expected, the practice of medicine and surgery is not an exact science and there cannot be any guarantee or warranty expressed or implied with regard to the results that may be obtained. Known risks have been disclosed, but the theoretical risk of unknown complications does exist.
It is important that you read the above information carefully and have all of your questions answered before signing this consent.
CONSENT FOR ANESTHESIA:
have read the foregoing consent and hereby confirm that I have: 1) had each item explained to me, 2) was given an opportunity to ask questions, and 3) had all of my questions answered. I understand the benefits, risks, alternatives and expectations of results to be achieved by this procedure.
I hereby authorize my Physician to perform Botox® Cosmetic, Xeomin®, or Dysport™ injections for the improvement of the appearance of the dynamic wrinkles on my face and neck or as they see fit to treat my medical or cosmetic conditions.