Neuromodulators Consent Form Preferred Location:*Please SelectLa Casita - 326 W. Craig PlaceSonterra - 18707 Hardy Oak BoulevardPatient Name: First Last Botox or Dysport therapy for wrinkles is an injection treatment designed to reduce facial expression lines. They are both approved by the FDA for the treatment of wrinkles in the glabellar area. When this therapy is performed, small amounts of toxin are injected into the facial muscles responsible for movement associated with lines and wrinkles. This injection weakens or paralyzes the muscle, thus reducing the associated lines and wrinkles. The most common areas for this therapy are the lines between the eyes, forehead wrinkles, crow’s feet and on occasion around the mouth. This therapy is temporary, meaning it has to be repeated on a regular basis to remain effective. The weakening effect gradually begins anywhere from 24 hours to 3 days, and is sometimes not complete for two weeks. During this period, you may notice asymmetry, or uneveness, within treated areas. This asymmetry will usually correct itself as the toxin takes effect. For maximal results it is recommended that you maintain an upright posture for at least 4 hours. During this time it is also recommended that the treated area not be rubbed vigorously or massaged. You may wish to actively move, by expression, the treated areas during this time, as this may help to increase the response of the targeted muscles.There are no known permanent side effects. There are, however, several possible side effects that are temporary, which include: Bruising: Occurs at or near the injection site. This effect clears within 7-10 days. No treatment is necessary.Headache: Related to the actual injections, is usually mild and transient, lasting less than 24 hours. May be reiieved with Tylenol. Asymmetry: As described above, if present, will be noticed in the first two weeks of therapy. May be corrected with “touch-up” injections if necessary. There may be a fee for touch-up injections. 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.Numbness: A change in sensation noticed by some patients in the treated areas, better described as “dullness”. It is usually only noticed for a few days after treatment. Eyebrows or eyelid ptosis (drooping) or diploia (double vision): Seen in 1-2% of patients receiving this therapy, is temporary, lasting weeks and usually mild. 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.Muscle weakness: 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. Also, for reasons not fully understood, some patients may be less sensitive or “resistant” to the effects of the toxins. Very deep creases may not be completely resolved with treatment.If you are pregnant or nursing, these treatments are not recommended. I understand more than one injection may be needed to achieve a satisfactory result. I certify that I have read this form and fully understand its contents I authorize photographs to be taken which may be used for medical publications, lay publications, education, or during lectures. I understand that I will not be entitled to any payment as a result of any of these images. Because this therapy for wrinkles is considered a cosmetic procedure, insurance does not pay for treatment. Payment at the time of service is requested for all patients.By signing below, I agree that I have read and understand the above information, and that my questions have been fully answered to my satisfaction. I understand that the practice of medicine and surgery is not an exact science and that results are not guaranteed. I agree to be personally and fully responsible for all fees.e-Signature :*Date This iframe contains the logic required to handle AJAX powered Gravity Forms.