Botox Therapy Consent Form
Please initial each section to indicate that you understand each topic. Do not initial if you desire
Injection of a very small amount of Botox®, a purified toxin produced by the bacterium clostridium botulinum,
into the specific muscle causes weakness or paralysis of that muscle. This results in relaxation of the muscle and
improvement of the lines or wrinkles that the muscle action has formed.
Response usually is seen 2-10 days after injection. Typically, the muscle action (and wrinkles) will return in 3-5
months. At this point, a repeat treatment will relax the muscle and soften the lines again. Initials: _____
I understand that several sessions may be needed to complete the injection series. I understand that there is a
separate charge for any subsequent treatment. Initials: _____
Risks and Complications
Possible side effects include: transient headache, swelling, bruising, pain during injection, twitching, itching,
numbness, asymmetry (unevenness), temporary drooping of eyelids or eyebrows. These side effects are rare, but
have been reported. In a very small number of individuals, the injection does not work as satisfactorily or for as
long as usual.
Known significant risks have been disclosed, yet the theoretical risk of unknown complications does exist.
Bruising may occur after Botox injections. Substances that increase the risk of bruising include Vitamin E, aspirin,
Motrin and other non-steroidal anti-inflammatory drugs. I understand that if I have taken any of the above within
the past 7 days, I have an increased risk of bruising. Bruising is also a significant risk with the use of blood thinning
medications such as Coumadin. I understand that if I am taking a blood thinning medication, this treatment may
result in significant bruising and may not be recommended. Initials: _____
I understand that there may be a higher possibility of side effects if I do not follow certain instructions and will
adhere to these instructions for at least 4 hours from the time of treatment. Initials: _____
Pregnancy & Neurological Disease
I understand that there are certain conditions where Botox® treatments are not recommended.
• Neurological disease, such as myasthenia gravis
• Pregnancy or breastfeeding
None of the conditions above apply to me. Initials: _____
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