Botox Consent Form

Stop taking medication that can thin the blood.
A week before you get Botox injections, stop taking:

• Aspirin
• Ibuprofen, either generic or Advil, Aleve or Motrin
• Excedrin
• St. John’s Wort
• Vitamin E
• Fish Oil or Omega-3’s
• Ginko Bilboa
• Ginseng

This will minimize any potential post-Botox bruising. If you have to take pain medication, Tylenol is okay.

• You should not be pregnant or nursing
• Avoid strenuous physical activity
• Avoid consuming large amounts of alcohol

The known complications could include:

• Redness. swelling/edema, itching, pain or pressure lasting more than one week
• Nodules or induration on/at the injection site
• Discoloration on the injection site
• Poor effect
• Allergic reactions
• The effects of Botox are apparent 2-5 days after treatment
• The effects usually last 4-6 months. Periodic retreatment will be necessary to maintain the effects of Botox
• Repeated treatment may lead to permanent loss of muscle tone in the treated area
• Bruising
• Facial asymmetry
• Paralysis leading to droopy eyelid and double vision
• Some patients may experience weakness or flu-like symptoms
• Some patients may develop antibodies to Botox

After Botox:

• No laying down or reclining for four hours after injection
• No scratching or rubbing the injected area
• No bending forward for four hours
• Makeup should be avoided for one to two hours after injection

CONSENT FOR BOTOX INJECTION

NATURE AND PURPOSE FOR BOTOX COSMETIC INJECTION

I authorize Altitude Dental to treat one or more of the following areas:

• Frown
• Forehead
• Crow’s feet
• Lower face

With injections of BOTOX Cosmetic for the purpose of attempting to cause the treated muscles to temporarily weaken or lose their function allowing the overlying skin lines to soften or smooth in appearance. BOTOX is a purified form of botulinum toxin A, a protein that is produced by the bacterium Clostridium botulinum. Injections of small amounts of botulinum toxin A into muscles block the release of a chemical that would otherwise signal the muscle to contract. The treatment usually begins to work within 24-48 hours; though the full effect may not be evident for 10-14 days and can last up to 4 months. The Food and Drug Administration (FDA) has approved the cosmetic use of Botulinum Toxin Type A for the temporary relief of moderate to severe frown lines between the brows and recommends that the procedure be performed no more frequently than once every three months. Treatment of other areas and at shorter intervals is considered an “off label” use of this product.

ALTERNATIVES

I understand that treatment alternatives may exist.

1. No treatment
2. Injection of filler material
3. Surgical procedures such as a forehead lift

RISKS AND COMPLICATIONS

The nature of the treatment to be performed has been explained to me in terms I understand.

• I understand that among the known risks are: Discomfort at the injection site, over relaxation of the overlying tissues such as the eyebrow or eyelid or interference with opening the eye(s).
• I am aware that in addition to risks specifically described above, there are known risks such as but not limited to: development of immune related “resistance” to Botox rendering further treatment ineffective, minor local swelling, bruising and/or redness at the injection site; transient headache, nausea and/or flu-like symptoms; transitory eyelid swelling, swallowing, speech or respiratory disorders, disorientation, double vision, temporary asymmetry of appearance, abnormal or diminished facial expression, inability to smile if injected in the lower face, facial pain, areas of numbness at the injections site, and product ineffectiveness.
• I understand and accept that long-term effects of repeated use of Botox are as yet unknown. Possible risks that have been identified include, but are not limited to: muscle atrophy, nerve irritability and production of antibodies with unknown effect to my general health.
• I understand that any improvement resulting from treatment of my present skin lines with Botox. Cosmetic is temporary and ultimately will require additional treatment to maintain.

PROPOSED TREATMENT

I acknowledge that the practice of medicine and surgery is not an exact science; therefore, reputable practitioners cannot guarantee or warranty:

• Specific results
• Risk free treatments
• Discomfort or pain free treatments
• Number of treatments needed for maximum improvement
• Length of effect of Botox Cosmetic, if any

MEDICAL HISTORY

• I have informed Altitude Dental of:
• All my known allergies
• All medications I am taking (prescriptions, over the counter and herbs)
• I am not currently pregnant or nursing

INFORMED CONSENT

I certify that I have read the consent for Botox Cosmetic injection.

I certify that I fully understand this consent for Botox Cosmetic injections and have had the opportunity to have any questions that I may have had answered to my satisfaction.

I understand that should I become pregnant while using this drug, there may be unknown risks, including birth defects.

I have been advised to seek immediate medical attention if swallowing, speech or respiratory disorders arise. I accept the remote risk of death or serious disability that exists with this procedure.

I accept full responsibility for choosing and requesting Botox Cosmetic injection, including any financial obligations incurred during the course of my treatment and the treatment of any complications that may arise as a result of this procedure.

I understand that no guarantee or assurances have been given as to the results of injections of Botox Cosmetic. Good results are expected, but are not guaranteed or warranted or that I MAY BE DISAPPOINTED WITH MY RESULTS.

I understand that it is the policy of this office that there will be NO REFUNDS FOR SERVICES ALREADY PROVIDED, either directly or in the form of additional injections of Botox Cosmetic at “no charge”.