Botox (Botulinum A Toxin) Informed Consent (Page 2 of 2) in pdf

10.

Another risk when injecting Botox around the eyes included corneal exposure because

people may not be able to blink the eyelids as often as they should to protect the eye. This

inability to protect the eye has been associated with damage to the eye as impaired vision,

or double vision, which is usually temporary. This reduced blinking has been associated

with corneal ulcerations. There are medications that can help lift the eyelid, however, if the

drooping is too great the eye drops are not that effective. These side effects can last for

several weeks or longer. This occurs in 2-5 percent of patients.

11.

I will follow all aftercare instructions as it is crucial I do so for healing.

As Botox is not an exact science, there might be an uneven appearance of the face with some

muscles more affected by the Botox than others. In most cases this uneven appearance can be

corrected by injecting Botox in the same or nearby muscles. However in some cases this uneven

appearance can persist for several weeks or months.

This list is not meant to be inclusive of all possible risks associated with Botox as there are both

known and unknown side effects associated with any medication or procedure.

Botox should not be administered to a pregnant or nursing woman.

Additionally,

The number of units injected is an estimate of the amount of Botox required to paralyze the

muscles. I understand there is no guarantee of results of any treatment. I understand the regular

charge applies to all subsequent treatments.

I understand and agree that all services rendered to me are charged directly to me and that I am

personally responsible for payment. I further agree in the event of non-payment, to bear the cost

of collection, and/or Court cost and reasonable legal fees, should this be required.

By signing below, I acknowledge that I have read the foregoing informed consent and agree to the

treatment with its associated risks. I hereby give consent to perform this and all subsequent Botox

treatments with the above understood. I hereby release the doctor, the person injecting the Botox and

the facility from liability associated with this procedure.

Patient Signature______________________________________Date: _____

Botox (Botulinum A Toxin) Informed Consent Page 2