Botox Consent

BOTOX WRINKLE TREATMENT INFORMED CONSENT FORM

You need to be fully informed about the details of BOTOX™ injections to improve the appearance of certain kinds of wrinkles.  Then you can make an informed decision whether to have this procedure based on your complete understanding of the risks and benefits.

  • Botulinum toxin Type A (brand name: BOTOX ™) has been safely used for many years for the treatment of facial muscle spasms and crossed eyes.  In recent years it has been used more commonly to treat over-active muscles of facial expression that can cause wrinkles.  In April 2002 it received FDA approval to smooth frown lines between the eyebrows.  BOTOX is a muscle relaxer, so injecting this medication into certain facial muscles causes them to be temporarily weakened and can smooth the wrinkles skin on top of the muscle.  Wrinkles that can be successfully treated are called dynamic wrinkles and include frown lines, smile lines and crow’s feet that appear when the muscles are scrunched together.  This treatment will not work to eliminate static wrinkles that appear all the time and are already deeply embedded in resting skin, or wrinkles due mainly from having loose or sagging skin.  Dr. Kanase will point out to you which of your wrinkles are likely to be helped by BOTOX and which probably won’t change.
  • Results are normally noticed within 3-5 days, but it may take as long as 2 weeks before the full effect of the treatment is realized.  The effects usually last from 3 to 5 months, at which time the procedure can be repeated, if desired.  A follow-up visit is recommended about 2 weeks after your first treatment to determine how well the muscles have been affected.  It may occasionally take more than one treatment to a given area to achieve full results.
  • After treatment you should keep your head and neck upright for 4 hours and should not touch, rub, or press on the treated area(s), as explained.  This helps to avoid the spread of BOTOX away from the desired area.
  • The most common side effects associated with BOTOX injections are redness, swelling, bruising, and minimal discomfort with the injection.  These are all temporary and can be reduced by applying ice briefly to the area.  Less commonly, there could be an allergic reaction, headache, or a very slight lowering of the skin above the eyelids.  Very rarely, treatment may cause temporary ptosis (drooping) of an upper eyelid or unevenness of an eyebrow.  None of these are every permanent and usually resolve completely within a few weeks.  In a small number of patients BOTOX may not work as well or last as long as expected to smooth the wrinkles.  A touch-up treatment may not improve the results in these cases.
  • BOTOX should not be given if you are pregnant, breast feeding, taking blood thinners, or have any neurological diseases, such as multiple sclerosis or myasthenia gravis.  The effects of the medication may be greater than expected if you are taking any of the aminoglycoside class of antibiotics, such as gentamicin, tobramycin, spectinomycin, neomycin, kanamycin, or amikacin.  You should notify Dr. Kanase before treatment if you have any of these conditions or if you are taking these medications.
  • BOTOX may not be right for everyone, and there are other alternatives to treat facial wrinkling.  You may consider other treatments available, such as collagen injections, facial plastic surgery, or having no treatment at all.  Some patients note that their headaches or migraine headaches improve following BOTOX treatment.
  • I understand that this treatment, like the practice of medicine itself, is not an exact science.  Therefore, NO SPECIFIC PROMISES OR GUARANTEES OF RESULTS CAN BE MADE for any degree of improvement of my particular condition.  There can be NO REFUNDS given for any treatment rendered, regardless of results.
  • I consent to taking pictures before or after the procedure to help to document my progress.  I will allow their use for any scientific, educational, or research purposes as deemed appropriate by Dr. Kanase as long as my name and identity are protected.
  • I CERTIFY THAT I HAVE READ AND UNDERSTAND THIS ENTIRE DOCUMENT AND IT HAS BEEN FULLY EXPLAINED TO ME.  I HAVE BEEN GIVEN AN OPPORTUNITY TO ASK QUESTIONS AND THEY HAVE BEEN ANSWERED TO MY SATISFACTION.
  • I UNDERSTAND THAT THE PAYMENT IN FULL FOR MY Botox™ IS DUE PRIOR TO MY FIRST TREATMENT AND THAT THIS IS NON-REFUNDABLE.
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