Neurotoxin Consent Form
Neurotoxins or Neuromodulators (Botox, Dysport Xeomin, Jeuveau, Daxxify) block neuromuscular activity in localized, small muscles which results in a temporary inability to make certain movements. Over time, this lack of movement will diminish the dynamic lines (lines or wrinkles caused by expression) as well as a decreased ability to frown. Injection results are usually dramatic and will improve the appearance of lines and wrinkles in the treated area for 120 days. In most cases, clients who continue these injections on a regular basis over a long period will see near-complete correction of their dynamic lines/wrinkles. Neurotoxins have been FDA approved for glabellar (frown lines) and squint lines around the eyes. Frequently, other areas are injected that are not FDA approved. This is considered “off label” use.
CONTRAINDICATIONS:
Do NOT undergo injections if you are allergic to or have had an allergic reaction to any ingredients found within Botox, Dysport, Xeomin or Daxxify
Use during pregnancy or in nursing mothers is NOT recommended
Infection at the proposed injection site
Pre-existing Neuromuscular Disorders such as ALS or Lou Gehrig’s Disease, Myasthenia Gravis, or Eaton-Lambert Syndrome
Are being treated for Cervical Dystonia, Dysphagia, or breathing difficulties
SIDE EFFECTS:
Discomfort at the injection site
Redness, small bums, or welts near injection site
Bruising
Bleeding
Dry mouth, tiredness, headache or neck pain, welling/drooping of the eyelids, or dry eyes
Symptoms of an allergy may include itching, rash, red itchy welts, wheezing or asthma symptoms, dizziness or feeling faint. Seek immediate medical help if you experience wheezing or feel dizzy or faint.
Damage to deeper structures such as nerves, blood vessels, and the eye may be damaged during the course of injection. Injury to deeper structures may be temporary or permanent.
Corneal exposure problems- difficulty closing eyelids
Dry eye problems
Migration of Neurotoxins- may migrate from its original injection site to other areas and produce temporary paralysis of other muscle groups or other unintended areas.
Drooping Eyelid (Ptosis)
Double vision
Eyelid ectropion
Asymmetry
Unknown risk- the long term effect of neuromodulators on tissue is unknown.
Antibodies to Neuromodulators- may reduce the effectiveness
Blindness- Blindness is extremely rare after injections.
MY SIGNATURE BELOW INDICATES THAT:
I certify that I have read and understand the above and that I have been given sufficient opportunity for discussion of all of my questions.
I confirm that I am not pregnant, breastfeeding, or have any significant neurological disease as noted above.
I consent to the taking of photographs and video and authorize their use for the purpose of medical audits and education. I understand my identity will be protected.
I understand that this is strictly a cosmetic procedure and individual results may vary. I have been given no guarantees as to the outcome, and I understand that the results are temporary and several sessions may be needed to achieve/maintain optimal results. All additional treatments are at additional cost.
My signature constitutes my consent for treatment with neurotoxin, and I understand that neurotoxins can have side effects including the spread of toxin effects and problems breathing or swallowing which can be life threatening. This can happen hours, days, or weeks after injection.
My signature also acknowledges that I have received and read a copy of Pre-Care and Post-Care instructions
By signing below, I acknowledge that I have read and understand the “Neurotoxin Consent” for this procedure, and that I am signing it voluntarily.
Patient Contact Details
Media Release
By checking this box, I confirm that I have read and understood the Informed Consent document for the procedure described above. I agree to the terms outlined in the document and give my consent to proceed.
