Patient
Consent Form
BOTOX Cosmetic
Botulinum Toxin Type A
Patient Name:
______________________________________________________
Chart #:___________________ Date:____________________
To the patient: Being fully informed about your condition and
treatment will help you make the decision whether or not to undergo BOTOX
Cosmetic treatment. This disclosure is
not meant to alarm you: it is simply an effort to better inform you so that you
may give or withhold your consent for this treatment.
I
have requested that Dr. Christine D’Antonio attempt
to improve my facial lines with BOTOX Cosmetic.
This is the Allergan Inc. trademark for Botulinum Toxin Type A.
These injections have been used for more than a decade to improve spasm
of the muscles around the eye, to correct double vision due to muscle imbalance
as well as numerous other neurological uses.
BOTOX Cosmetic is now approved by the FDA to improve the appearance of
the vertical lines between the brows. A
few tiny injections of BOTOX Cosmetic relax overactive muscles and soften those
vertical lines. Injections in other
areas to improve appearance of facial lines have been reported in the
literature, but the FDA has not approved those uses. The results of BOTOX Cosmetic are usually
dramatic, although the practice of medicine is not an exact science and no
guarantees can be or have been made concerning expected results.________Patients
Initials
The
BOTOX Cosmetic solution is injected with a tiny needle into the muscle; you
should see the benefits develop over the next two to seven days. A decreased appearance of frowning or
creasing of other lines will be the result of this treatment.________Patient
Initials
The
most common side effects are headache, respiratory infection, flu syndrome,
temporary eyelid or brow droop, double vision, dry eyes, bruising, and
nausea. BOTOX Cosmetic should not be
used if there is an infection at the injection site. I have been advised of the risks involved in
such treatment, the expected benefits of such treatment, and alternative
treatments, including no treatment at all.________Patient
Initials
I understand that the results are temporary and several
sessions may be needed for optimal results.________Patient
Initials
I
agree that this constitutes full disclosure, and that it supersedes any
previous verbal or written disclosures.
I certify that I have read, and fully understand the above paragraphs,
and that I have had sufficient opportunity for discussion and to ask questions. I consent to this BOTOX Cosmetic treatment
today and for all subsequent treatments.
Patient’
Signature:______________________________
Date:__________________
Physician’s
Signature:___________________________
Date:__________________