Scroll down to find these forms:

  1. Botulinum toxin consent
  2. Cheat sheets (link)
  3. Injectable fillers

PATIENT CONSENT FORM FOR TREATMENT WITH BOTULINUM TOXIN  

 

I (neatly print patient name)……………………………………………………….. hereby request to have Botox®  injected into the muscles of my face. 

If any of these apply to you, you should not continue with this treatment today. Check the following that applies to you: taking antibiotics____, disease causing muscle weakness___,  pregnant___, breastfeeding___, stomach disease___, had a stroke___. taking medication for depression(not recommended for injections into lips only)___ .

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The indication that I am being treated for may not printed on the label of the Botox vial (off-label). The treatment has been accepted for a therapeutic indication. I am aware that the outcome is often unpredictable and may not be to my satisfaction.

I have been instructed that the material risks in this procedure includes loss of facial expression, lines and wrinkles, asymmetry, drooping (ptosis) of the mouth, eyebrow and/or eyelid ; bruising, pain, headaches, bleeding, tenderness, swelling, redness at injection sites. The medication may spread to the brain and other parts of the body. On rare occasions there may be allergic reactions, infection, numbness, tingling, paralysis or partial paralysis; loss of facial expressions, loss of blood and scarring, disfiguring scars; cardiac arrest, brain damage, death. There may also be other unspecified risks and unknown long-term risks.

I will seek immediate medical attention should I notice the following effects after administration of Botox (Botulinum toxin): dysphagia (difficult swallowing), dysphonia (difficult speaking), weakness, dyspnea  (difficult breathing)                   I am aware that these effects may occur up to several weeks after treatment

I realize that during the course of this procedure other conditions may arise or may have to be treated and I hereby consent to any additional procedure or treatment which the healthcare provider deems necessary or appropriate to treat such conditions.

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I also understand that treatment may be ineffective or have a limited duration of effect.

I understand that I may choose to stop the above procedure at any time.

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I have been instructed to avoid bending over, touching or washing injection sites, removing facial make-up, lying down, sleeping or working out for 4 hours after treatment. 

I understand that I will be responsible for all legal fees that may arise from any and all frivolous lawsuits that I may initiate. I understand that all cases will be aggressively defended by the treating doctor. I have read, understand and agree to all of the above.

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Signed (patient/ guardian)_____________________________Date_________________

This form must be signed by the patient or by the legal guardian in the case of a minor or physically/cognitively disabled adult. 

 

Injector’s signature_____________________________Date________________

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2.64.Cheat Sheets

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3. Injectible fillers consent form:

                    PATIENT CONSENT FORM   –  FILLERS  

I (neatly print patient name)……………………………………………………….. hereby volunteer and request to have an injectible filler material injected into my face and lips.

I am aware that the outcome may not be to my satisfaction. I have been advised to have these procedures performed while anesthetized with injectible local anesthetic which may impair speech, swallowing and chewing. I am aware that the effects of the local anesthesia may be prolonged

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I do not have any infections nor do I have any artificial joints or heart condition that requires antibiotics before treatment. I am not taking steroids nor do I have an inflammatory disease. I understand it is unsafe to proceed should I have any of these conditions.

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I understand that treatment may be ineffective or have a limited duration of effect. I also understand that I may require additional treatment and material that will cost me an additional amount both for treatment and filler materials.

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I understand that the areas of injection will enlarge due to inflammation immediately after injections, and the inflammation can last for up to 7 days. I may have to take medication to treat the inflammation that include anti-inflammatories and/ or steroids

I  have been instructed that the unlikely material risks in this procedure includes drooping (ptosis) of the mouth, facial asymmetry, bruising, pain, headaches, bleeding, tenderness, swelling, redness at injection sites. On rare occasions there may also be allergic reactions, infection; numbness, tingling, paralysis or partial paralysis; loss of facial expressions, loss of blood and scarring, disfiguring scars; cardiac arrest, brain damage, death. There may be other unspecified risks and unknown long-term risks.

I realize that during the course of this procedure other conditions may arise which require immediate attention and I hereby consent to any additional procedure or treatment which the healthcare provider deems necessary or appropriate to treat such conditions. These treatments may include antibiotics, steroids and anti-inflammatories.

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I have been instructed to avoid bending over, touching or washing my face, sleeping or working out/ exercising for 4 hours after treatment. I should also avoid the use of alcohol and cigarettes on the day of treatment.

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I understand that I will be responsible for all legal fees that may arise from any and all frivolous lawsuits that I may initiate pertaining to this treatment. I understand that all cases will be aggressively defended by the treating doctor.

 

I understand that I may terminate the above procedure at any time.

I have read, understand and agree to all of the above.

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Signed by patient: _____________________________Date_________________  

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Injector__________________________________________________

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