Full Name

Full Address

Date of birth
I understand that I will be injected with Botulinum A
Toxin (Botox) in the area of the glabella muscles to paralyze these muscles temporarily or in the
forehead or crow’s feet around the lateral area of the eyes.
Botulinum A Toxin (Botox) injection has been FDA approved for use in the cosmetic treatment for
glabellar frown lines only – the wrinkles between the eyebrows.
Injection of Botox into the small muscles between the brows causes those specific muscles to halt their
function (be paralyzed), thereby improving the appearance of the wrinkles. I understand the goal is to
decrease the wrinkles in the treated area. This paralysis is temporary, and re-injection is necessary
within three to four months. It has been explained to me that other temporary and more permanent
treatments are available.
I Understand the possible side effects of Botox include but are not limited to the below

1 Risks: I understand there is a risk of swelling, rash, headache, local numbness, pain at the injection
site, bruising, respiratory problems, and allergic reaction.

2. Infection: Infections can occur which in most cases are easily treatable but in rare cases a permanent
scarring in the area can occur.

3. Most people have lightly swollen pinkish bumps where the injections went in, for a couple of hours or
even several days.

4. Although many people with chronic headaches or migraines often get relief from Botox, a small
percent of patients get headaches following treatment with Botox, for the first day. In a very small
percentage of patients these headaches can persist for several days or weeks.

5. Local numbness, rash, pain at the injection site, flu like symptoms with mild fever, back pain.

6. Respiratory problems such as bronchitis or sinusitis, nausea, dizziness, and tightlloooooo irritationl of
the skin.

7. Bruising is possible anytime you inject a needle into the skin. This bruising can last for several hours,
days, weeks, months and in rare cases the effect of bruising could be permanent.

8. While local weakness of the injected muscles is representative of the expected pharmacological action
of Botox, weakness of adjacent muscles may occur as a result of the spread of the toxin.

9. Treatments: I understand more than one injection may be needed to achieve a satisfactory result.

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.
Practitioner Sign
Photo of clients face forward, and side view.
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.