Botox and Dysport Consent Form

BOTOX® Cosmetic, Xeomin® and/or Dysport® are indicated for the temporary improvement in the appearance of moderate to severe glabellar lines associated with corrugators and/or procerus muscle activity in patients 18 to 65 years of age.

BOTOX® Cosmetic, Xeomin® and/or Dysport® onset of action is approximately 5-7 days, typically one treatment lasts between three to four months. Injection medication may migrate based on your posture after treatments (laying down, sitting up, and exercising).

Post marketing reports indicate that the effects of BOTOX® Cosmetic, Xeomin® and/or Dysport® and all botulinum toxin products may spread from the area of injection to produce symptoms consistent with botulinum toxin effects. These may include asthenia, generalized muscle weakness, diplopia, blurred vision, ptosis, dysphagia, dysphonia, dysarthria, urinary incontinence, and breathing difficulties. These symptoms have been reported hours to weeks after injection. Swallowing and breathing difficulties can be life threatening, and there have been reports of death.

BOTOX® Cosmetic, Xeomin® and/or Dysport® are contraindicated in the presence of infection at the proposed injection sites(s) and in individuals with known hypersensitivity to any botulinum toxin preparation or to any of the components in the formulation. It is important that you notify the physician if any of these apply to you prior to the administration of BOTOX® Cosmetic, Xeomin® and/or Dysport® .

The recommended dosage and frequency of administration for BOTOX® Cosmetic/Xeomin®/Dysport® should not be exceeded. Risks resulting from administration at higher dosages are not known. If you exceed the amount that the physician recommends there is a higher chance for side effects to occur.

Serious and/or immediate hypersensitivity reactions have been reported. These reactions include anaphylaxis, urticaria, soft-tissue edema, and dyspena. If such reactions occur, further injection of BOTOX® Cosmetic, Xeomin® and/or Dysport® should be discontinued and appropriate medical therapy immediately instituted. One fatal case of anaphylaxis has been reported in which lidocaine was used as the diluents and, consequently, the casual agent cannot be reliably determined.

Individuals with peripheral motor neuropathic diseases, amyotrophic lateral sclerosis, or neuromuscular junctional disorders (e.g., myasthenia gravis or Lambert-Eaton syndrome) should be monitored particularly closely when given botulinum toxin. Individuals with neuromuscular disorders may be at increased risk of clinically significant effects including sever dysphagia and respiratory compromise from typical doses of BOTOX® Cosmetic, Xeomin®, and/or Dysport®.

If loss of strength, muscle weakness, or impaired vision occurs, you should avoid driving a car or engaging in other potentially hazardous activities until symptom(s) subsides.

I understand “touch ups” of Botox® Cosmetic, Xeomin®, Dysport® require an additional fee.

Administration of BOTOX® Cosmetic, Xeomin® and/or Dysport® is not recommended during pregnancy. There are no adequate and well-controlled studies of BOTOX® Cosmetic in pregnant women. You must notify your physician if you have any chance of being pregnant at the time of administration of BOTOX® Cosmetic.

It is not known whether BOTOX® Cosmetic, Xeomin® and/or Dysport®are excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when BOTOX® Cosmetic and/or Dysport® are administered to a nursing woman. You must notify your physician if you are breast feeding at the time of administration of BOTOX® Cosmetic, Xeomin® and/or Dysport®.

The most serious adverse events reported after treatment with botulinum toxin include spontaneous reports of death, sometimes associated with anaphylaxis, dysphagia, pneumonia, and/or other significant debility. There have also been reports of adverse events involving the cardiovascular system, including arrhythmia and myocardial infarction, some with fatal outcomes. Some of these individuals had risk factors including pre-existing cardiovascular disease. It is important that you notify the physician if you have pre-existing cardiovascular conditions prior to the administration of BOTOX® Cosmetic, Xeomin® and/or Dysport®.

The most frequently reported adverse events following injection of BOTOX® Cosmetic, Xeomin® and/or Dysport® include blepharoptosis and nausea.

Excessive doses of BOTOX® Cosmetic, Xeomin® and/or Dysport® may be expected to produce neuromuscular weakness with a variety of symptoms. Respiratory support may be required where excessive doses cause paralysis of respiratory muscles. It is important that you notify the physician of your last BOTOX® Cosmetic and/or Dysport® treatment. If you are feeling short of breath after your treatment notify the physician immediately of get any other medical assistance immediately.

I have read and understood all of the possible side effects associate with the administration of BOTOX® Cosmetic, Xeomin® and/or Dysport®, I have asked all questions necessary, I have not withheld any medical information regarding any conditions I may have or medications that I am taking, and I give my consent to receive BOTOX® Cosmetic, Xeomin® and/or Dysport®.

I give permission to the staff of Dr. K’s Med Spa to take my before and after the treatment and to use the pictures for business purposes. I understand that results may vary and that the BOTOX® Cosmetic, Xeomin® and/or Dysport® need now. I understand all side effects associated with BOTOX® Cosmetic, Xeomin® and/or Dysport® treatment.

I understand that results are not guaranteed and that results can vary.