Informed Consent

BOTOX (Botulinum A Toxin), DYSPORT, AND/OR XEOMIN

INFORMED CONSENT

I, ______________________________________________________, understand that I will

be injected with Botulinum A Toxin (Botox), Dysport, and/or Xeomin in the area of the

glabella muscles to paralyze these muscles temporarily or in the forehead or crows feet

around the lateral area of the eyes.

Botulinum A Toxin (Botox), Dysport, and/or Xeomin injection has been FDA approved for use in

the cosmetic treatment for glabellar frown lines only – the wrinkles between the eyebrows.

Injection of Botulinum A Toxin (Botox), Dysport, and/or Xeomin into the small muscles between

the brows causes those specific muscles to halt their function (be paralyzed), thereby improving the

appearance of the wrinkles. I understand the goal is to decrease the wrinkles in the treated area.

This paralysis is temporary, and re-injection is necessary within three to four months. It has been

explained to me that other temporary and more permanent treatments are available.

The possible side effects of Botulinum A Toxin (Botox), Dysport, and/or Xeomin include but are

not limited to:

1. Risks: I understand there is a risk of swelling, rash, headache, local numbness, pain at

the injection site, bruising, respiratory problems, and allergic reaction.

2. Infection: Infections can occur which in most cases are easily treatable but in rare cases a

permanent scarring in the area can occur.

3. Most people have lightly swollen pinkish bumps where the injections went in, for a couple of

hours or even several days.

4. Although many people with chronic headaches or migraines often get relief from Botulinum

A Toxin (Botox), Dysport, and/or Xeomin, a small percent of patients get headaches

following treatment with Botox, for the first day. In a very small percentage of patients these

headaches can persist for several days or weeks.

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

6. Respiratory problems such as bronchitis or sinusitis, nausea, dizziness, and tightness or

irritation of the skin.

7. 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.

8. While local weakness of the injected muscles is representative of the expected

pharmacological action of Botulinum A Toxin (Botox), Dysport, and/or Xeomin, weakness

of adjacent muscles may occur as a result of the spread of the toxin.

9. Treatments: I understand more than one injection may be needed to achieve a satisfactory

result.

10. Another risk when injecting Botulinum A Toxin (Botox), Dysport, and/or Xeomin 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.

This reduced blinking has been associated with corneal ulcerations. There are medications

that can help lift the eyelid, however, if the drooping is too great the eye drops are not that

effective. These side effects can last for several weeks or longer. This occurs in 2-5

percent of patients.

11. I will follow all aftercare instructions as it is crucial I do so for healing.

As Botulinum A Toxin (Botox), Dysport, and/or Xeomin 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 Botulinum A Toxin

(Botox), Dysport, and/or Xeomin as there are both known and unknown side effects associated with

any medication or procedure.

Botulinum A Toxin (Botox), Dysport, and/or Xeomin should not be administered to a pregnant or

nursing woman.

Additionally,

The number of units injected is an estimate of the amount of Botulinum A Toxin (Botox),

Dysport, and/or Xeomin 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

Botulinum A Toxin (Botox), Dysport, and/or Xeomin treatments with the above understood. I

hereby release the doctor, the person injecting the Botulinum A Toxin (Botox), Dysport, and/or

Xeomin and the facility from liability associated with this procedure.

Patient Signature______________________________________Date: _____