Consent to Botox Botulinum Toxin “A” Treatment

Botoxis a neurotoxin produced by the bacterium Clostridium A. Botoxcan relax the
muscles on areas of the face and neck which cause wrinkles associated with facial
expressions. Treatment with Botox can cause your facial expression lines or wrinkles to
essentially disappear. Areas most frequently treated are a) glabellar area of frown lines,
located between the eyes; b) crow’s feet (lateral areas of the eyes); and c) forehead
wrinkles. Botox is diluted to a very controlled solution and when injected into the
muscles with a very thin needle, it is almost painless. Clients may feel a slight burning
sensation while the solution is being injected. The procedure takes about 15-20 minutes
and the results last 3-6 months. With repeated treatments, the results may tend to last
longer.

RISKS AND COMPLICATIONS

It has been explained to me that there are certain inherent and potential risks and side
effects in an invasive procedure and in this specific instance such risks include but are
not limited to: 1. Post treatment discomfort, swelling, redness and bruising 2. Double
vision 3. A weakened tear duct 4. Post treatment bacterial, and/or fungal infection
requiring further treatment 5. Allergic reaction 6. Minor temporary droop of eyelid(s) in
approximately 2% of injections, this usually lasts 2-3 weeks 7. Occasional numbness of
the forehead lasting up to 2-3 weeks 8. Transient headache, and 9. Flu-like symptoms
may occur.

PHOTOGRAPHS

I authorize the taking of clinical photographs and their use for scientific purposes both in
publications and presentations.

PAYMENT

I understand that this is an “elective” cosmetic procedure, and that payment is my
responsibility and is expected at the time of treatment.

RIGHT TO DISCONTINUE TREATMENT

I understand that I have the right to discontinue treatment at any time.

CONSENT TO BOTOX BOTULINUM TOXIN “A” TREATMENT

ALTERNATIVE PROCEDURES

Alternatives to the procedures and options that I have volunteered for have been fully
explained to me.

RESULTS

I am aware that when small amounts of purified botulinum (“BOTOX”) are injected into a
muscle it causes weakness or paralysis of that muscle. This appears in 2-10 days and
usually lasts 3-6 months but can be shorter or longer. In a very small number of
individuals who do not respond at all. I understand that I will not be able to “frown” while
the injection is effective but that this will reverse after a period of months at which time
re-treatment is appropriate. I understand that I must stay in the erect posture and that I
must not manipulate the area(s) of the injections for the 2 hours post-injection period.
I understand this an elective procedure and I hereby voluntarily consent to treatment
with Botox injection for Facial Dynamic Wrinkles, TMJ, or Bruxism. The procedure has
been fully explained to me. I have read the above and understand it. My questions have
been answered satisfactorily. I accept the risks and complications of the procedure and I
understand that no guarantees are implied as to the outcome of the procedure. I also
certify that if I have any changes in my medical history, I will notify the office
immediately. I also state that I read and write in English.