To the patient:
It is important that you are informed about your skin condition and proposed treatment including the potential benefits and risks involved. This disclosure is not meant to scare or alarm you; it is simply an effort to better inform you so that you may give or withhold your consent to the treatment program.
BOTOX® or DYSPORT® are the tradenames for purified botulinum toxin type A and are used to relax wrinkle causing muscles. BOTOX® and DYSPORT® treatments have been used for more than 20 years in children and adults to treat therapeutic conditions such as involuntary facial muscle spasms and double vision due to eye muscle imbalances. Injection of tiny amounts of BOTOX® or DYSPORT® weaken the treated muscle/s and helps prevent the formation of expression lines. BOTOX® and DYSPORT® are included on the Australian Register of Therapeutic Goods (ARTG) for cosmetic use in frown lines.
The practice of medicine is not an exact science and no guarantees can be or have been made concerning expected results. I understand that several appointments may be necessary to complete the treatment.
I am aware that when small amounts of purified BOTOX® or DYSPORT® are injected into a muscle it causes weakness in that muscle. This takes 4-7 days to take effect and usually lasts 4 months but can be for a longer or shorter period.
I understand that the muscles injected will not function whilst the injection is effective (e.g: I will not be able to frown if the muscles involved in frowning are injected) but that this will reverse itself after a period of months at which time re-treatment is appropriate.
Risks and side effects:
Side effects and complications are usually minimal. Occasionally, headache, slight swelling, and/or bruising may occur after injection. An adjacent muscle may be weakened for several weeks after an injection, which may cause a temporary drooping of the eyelid or an eyebrow. This could last 2-3 weeks. 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.
* Please do not rub the injected area immediately after the treatment.
Please remain upright for 4 hours after the injection.
Pregnancy and Neurologic Disease: I am not aware that
I am pregnant and I do not have any neurologic disease. Please notify your doctor if you have any allergies, autoimmune disease or are taking any medications or herbal supplements.
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® injection procedure today and for all subsequent treatments.
PLEASE TAKE THE TIME TO READ THIS CAREFULLY AND TO UNDERSTAND ANY ACCOMPANYING INFORMATION
