Botox Consent Form

  • Botox Consent Form

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  • Botox therapy for wrinkles is an injection treatment designed to reduce facial expression lines. Botox is the trade name for Botulinum purified protein complex. When tiny amounts of Botox are injected into the facial muscles responsible for movement, those lines that wrinkle, are directly associated with this muscle movement and are diminished by weakening the muscle. Thus, Botox therapy works best for “dynamic” lines and wrinkles and is less effective for fine textural changes in the skin surface, and for those lines present at rest.
    Botox therapy is temporary, meaning it will have to be repeated on a regular basis to remain effective. The average response is 3 to 6 months of diminished muscle contraction, although there have been reports of more than 6 months of efficacy following a single injection. Individual responses may be longer or shorter depending on the degree of skin sun damage, depth of the lines, the size of the muscle, and the amount of Botox used in the injection. After a Botox injection, the effect gradually begins over several days and is not complete for 2 weeks, and sometimes longer. The effects of Botox therapy often become longer after repeated injections. Botox therapy may be combined with other cosmetic facial procedures such as photo rejuvenation, micro-dermabrasion, and filler injections to enhance the appearance.
  • For maximal results, it is recommended that after receiving Botox you do not vigorously rub or massage the treated area for 2 hours. You should actively contract the treated muscles (for example, frown or grimace) to increase the response of the Botox for 2 hours following the treatment.
    There is no known permanent side effect of Botox therapy for wrinkles. Botox therapy has been used for wrinkles since 1987, and is considered an extremely safe procedure by doctors. There are several temporary side effects which include pain and possible bruising at the injection site; transient numbness, and transient muscle asymmetry which can be treated with touch-up injections. Less than 1% of patients receiving Botox can experience temporary eyebrow or eyelid drooping and/or double vision if the Botox affects the muscles which move the eye and eyelid. This effect usually only lasts up to four weeks. Some patients may be less sensitive to Botox, and therapy will not work as well for them as expected. Contraindications to Botox therapy include pregnancy, breastfeeding, active skin infection in the area treated, neurological diseases like myasthenia gravis, and the drug penicillamine. Alternatives to Botox therapy include no treatment, topical creams, chemical, and laser peels, photo rejuvenation, or a surgical face, brow, or eyelid lift.
  • The price of Botox therapy depends on the amount of Botox injected, which varies from person to person. You may request a price quote prior to treatment which consists of an estimated range of cost for the site that you wish to be treated. I certify that I have read this entire informed consent and that I understand and agree to the information provided on this form and thus, authorize Dr. Jeff Bullock and the Parkway Smiles Dental team to perform one or more Botox therapy sessions.
    I agree to have my photograph taken to document my condition. A member of the Parkway Smiles Dental team has explained the nature of my condition, the nature of the procedure and alternative treatments, and the benefits to be reasonably expected compared with alternative approaches. This document is a written confirmation of this discussion. My questions have all been answered to my satisfaction. I agree to follow the post-injection treatment instructions.
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