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Patient Botox/Dysport Consent

Botulinum Toxin is neurotoxin produced by the bacterium Clostridum A, that can relax the muscles on areas of the face which cause wrinkles associated with facial expressions. Treatment with Botox/Dysport can cause facial lines or wrinkles to essentially disappear. Areas most frequently treated are: 1) glabellar area or frown lines located between the eyes, 2) crow’s fee (lateral areas of the eyes); and 3) forehead wrinkles. Botox/Dysport is diluted to a very controlled solution, and when injected into the muscles with a very thin needle, it is almost painless. Patients may feel a slight burning sensation while the solution is being injected. The procedure takes about 15-20 minutes and the results last 3-5 months. With repeated treatments, the results may last longer.

Risks and Complications

It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure. With this specific treatment, such risks include but are not limited to 1) post treatment discomfort, 2) post treatment bacterial, viral and/or fungal infection requiring further treatment, 3) allergic reaction, 4) minor temporary droop of the eyelid(s) in approximately 2% of injections usually lasting 2-3 weeks, 5) occasional numbness of the forehead lasting up to 2-3 weeks, 6) transient headache, and 7) occurrence of flu-like symptoms or 8) bleeding, redness, bruising, and/or edema of the injected areas.

Pregnancy, Allergies, and Neurologic Disease

Please initial:

I am not pregnant

I do not have or ever have had a neurologic disease

I am not allergic to the toxin ingredients or to human albumin

Results

I am aware that when small amounts of purified botulinum toxin (Botox/Dysport) are injected into a muscle, it causes weakness or paralysis of that muscle. This appears in 3-14 days and usually lasts 2-5 months, but can be shorter or longer. In a very small number of individuals, the injection does not work as satisfactorily or for as long as usual. I understand that I will not have total muscle movement while the injection is effective, but that will reverse after a period of months at which time re-treatment is appropriate. I understand that I must stay in the erect posture and that I must not touch or manipulate the area of injection for 4 hours after the treatment.

I understand that results might vary and that if a touch up or correction is needed that I need to wait a minimum of 2 weeks after my initial injection as the full effect of the product will not be known until then. I need to wait a minimum of 2 weeks to receive any skincare services.

A minimum of $150 will be charged regardless of the amount of neuromodulator injected.

I hereby volunteer consent to treatment with Botox/Dysport injection. The procedure/treatment has been explained to me. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure.

Cancellation Policy:

Your allocated appointment times are reserved especially for you and are very important to us. We have implemented this cancellation policy because we value the business of our clients and the time of our staff. All of our policies are designed to benefit our current clients and our future clientele. Therefore, we respectfully request at least 24 hours’ notice for adjustments to your appointments and for cancellations. Please understand that when you forget or cancel your appointment without giving enough notice, we miss the opportunity to fill that appointment time and clients on our waiting list miss the opportunity to receive services they need.

I understand that as a new or current client of Skinlogic Med Spa that I supply a credit card to have on our files. All cards on file are added to the system via a secure electronic process that ensures the information is encrypted and remains secure. In the event that we do not receive the required 24 hour notice for adjustments and cancellations a $50 fee will be applied to your card.

I have read the above Cancellation Policy and agree to its terms and conditions. I hereby give my consent for Skinlogic Med Spa to securely store my credit card on file and authorize Skinlogic Med Spa to charge my card if I cancel less than 24 hours before any future scheduled appointments.

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May 13, 2020 10:26 pm PDT

Patient Botox/Dysport Consent Uploaded by Skinlogic Med Spa - infossc2001@gmail.com IP 73.169.190.108