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About Botox Cosmetic Form [ 1.32 MB]

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BOTOX Cosmetic® Pre-Treatment Instructions

  1. Stop all anti-inflammatories, aspirin, Advil, Aleve 7 days prior to injection. If a physician prescribes the anti-inflammatory, consult with them first prior to stopping the medication. You may continue taking anti­ coagulants but this will increase your risk of bruising. Herbal supplements such as fish oil, Vitamin E and C can increase your risk of bruising. Please stop all herbal supplements 7 days prior to your visit.

  2. Bruising is a common side effect.

  3. If you are nursing or pregnant you will not be injected.

  4. Neuromuscular disease is a contraindication to injection. If you have myasthenia gravis, MS or another similar condition you may not qualify for BOTOX injection.

  5. Calcium channel blockers (a type of blood pressure medication) and Amino glycoside antibiotics can interfere with BOTOX. If you are taking any such medication, make sure your doctor is aware.

  6. If you have an active infection on your face you will not receive an injection of BOTOX.

BOTOX Cosmetic® Post Treatment Instructions

  1. Try to exercise your treated muscles for 1-2 hours after treatment. (e.g. practice frowning, raising your eyebrows or squinting.) This helps to work BOTOX Cosmetic® into your muscles. Although this is thought to help, it will NOT impact your treatment negatively if you forget to do this.

  2. Do NOT rub or massage the treated areas for 4 hours after your treatment. Do NOT do Yoga or any type of strenuous exercise for 4 hours after treatment. Also, avoid facials or saunas for 4 hours after your treatment. This will minimize the risk of raising your blood pressure and therefore minimize the risk of temporary bruising. Feel free to shower and go about most other regular daily activities.

  3. Do NOT lie down for 4 hours after treatment. This is to avoid the risk of pressure on the treated areas (from your pillow) and to avoid the risk of having the areas rubbed accidentally.

  4. Be assured that any tiny bumps or marks will go away within a few hours. If you need to apply makeup within 4 hours after your treatment, only use a GENTLE touch to avoid rubbing the treated area.

  5. Results of your treatment may take up to 14 days to take full effect. Please wait until the 14 days have passed before assessing if you are pleased with the result.

  6. BOTOX Cosmetic® is a temporary procedure and at first, you may find that your treatment results will last approximately 3 or 4 months. If you maintain your treatment appointments with the frequency recommended by your doctor the duration of each treatment result may last longer than 4 months.


BREVARD EAR, NOSE AND THROAT CENTER

1099 Florida Avenue
Rockledge, FL 32955
Phone: 321-632-6900
Fax 321-639-7222

Botulinum Therapy Consent Form

Please initial each section to indicate that you understand each topic. Do not initial if you desire more information.

Proposed Treatment

Injection of a very small amount ofBOTOX®, a purified toxin produced by the bacterium Clostridium botulinum, into the specific muscle causes weakness or paralysis of that muscle. This results in relaxation of the muscle and improvement of the lines or wrinkles that the muscle action has formed.

Anticipated Benefit

The response usually is seen 2-10 days after injection. Typically, the muscle action (and wrinkles) will return in 3-5 months. At this point, a repeat treatment will relax the muscle and soften the lines again.

I understand that several sessions may be needed to complete the injection series. I understand that there is a separate charge for any subsequent treatment.

Risks and Complications

Possible side effects include a transient headache, swelling, bruising, pain during injection, twitching, itching, numbness, asymmetry (unevenness), temporary drooping of eyelids or eyebrows. These side effects are rare but have been reported. In a very small number of individuals, the injection does not work as satisfactorily or for as long as usual. Known significant risks have been disclosed, yet the theoretical risk of unknown complications does exist.

Bruising may occur after BOTOX® injections. Substances that increase the risk of bruising include Vitamin E, aspirin, Motrin and other non-steroidal anti-inflammatory drugs. I understand that I have taken any of the above within the past 7 days, I have an increased risk of bruising. Bruising is also a significant risk of the use of blood thinning medications such as Coumadin. I understand that I am taking a blood thinning medication, this treatment may result in significant bruising and may not be recommended.

I understand that there may be a higher possibility of side effects if I do not follow certain instructions and will adhere to these instructions for at least 4 hours from the time of treatment.

These include:

  • I will not lie down or bend forward for extended periods of time for at least 4 hours from the time of treatment.
  • I will not manipulate or massage the treated area for at least 4 hours after the treatment.

Pregnancy & Neurological Disease

I understand that there are certain conditions where BOTOX® treatments are not recommended. These include:

  • Neurological disease such as myasthenia gravis.
  • Pregnancy or breastfeeding.

None of these conditions apply to me.

Limitations and Alternatives

BOTOX® is best at treating dynamic facial lines, those caused by facial muscle activity; lines present at rest may or may not improve. A treatment may be effective for variable lengths of time with subsequent treatments, may not work as well or for as long as expected, or may not work at all.

Cost/Fees

Payment for this cosmetic procedure is my responsibility. I understand that there will be an additional fee for touch-ups.

Follow-up

I agree to follow up in 2-4 weeks after my first treatment if asked to do so by my physician.

Photographs

I authorize the taking of clinical photographs and their use for scientific purposes both in publications and presentations. I understand my identity will be protected.

I have read the above and understand it. My questions have been answered satisfactorily by the doctor and doctor's associates. I accept the risks and complications of the procedure.