as

Botox Consent

CONSENT FOR TREATMENT WITH BOTOX/DYSPORT

         I authorize the treating physician and/or assigned healthcare professional to perform BOTOX Cosmetic® treatments in order to reduce the appearance of my facial wrinkles in the areas treated. I understand that BOTOX Cosmetic® relaxes the muscles under my skin and therefore reduces the wrinkling caused by muscular contraction. I understand that tiny amounts of BOTOX Cosmetic® will be injected into the muscles and that this will cause my muscles to temporarily relax for approximately four months. Although results are commonly predictable and provide a good outcome, I understand that no guarantees can be made concerning expected results.

         I understand that it can take up to 14 days for the full result, although the benefits may begin to develop within the first few days. I understand that the areas treated will have a reduction of muscle movement and that there is no guarantee that wrinkles will be completely removed. I understand that the lines directly under the eyes are not affected.

         I understand that side effects or complications are rare and not permanent. Occasionally, slight swelling, and/or bruising may last for several days after the injections. Rarely, a nearby muscle may be weakened for several weeks after the treatment. There is very rare chance of upper eyelid or brow weakness, which could mean the top eyelid or brow could droop for a month or more. This is temporary and always resolves.

         I understand that photographs may be taken before and after the treatment for my medical records.

         I have been given instructions on care after the injection and agree to follow these.

         I have read the above information and have discussed the risks and benefits of this procedure to my satisfaction with the doctor and/or his assigned healthcare professional.

         I recognize that not having this procedure is an option.

         I recognize that this is a cosmetic procedure and that there is an associated fee.