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MIRAGE Salon & MedSpa
Informed Patient Consent for Botulinum Toxin Injection (BOTOX)
Botulinum Toxin Type-A As BOTOX from Allergan
For the temporary treatment of superficial facial wrinkles
I certify that I am a competent adult of at least 18 years of age
I certify that I am a minor under the age of 18 and understand that the consent of my parent/legal guardian will also be required before treatment.
I certify that the nature and purpose of the treatment has been explained to me and questions I have regarding the treatment have been answered to my satisfaction.
I understand surgery or other treatment alternatives may be as effective, or more effective, in reducing the appearance of wrinkles.
I am fully aware of the risks of complications or injuries that can occur from this treatment, both from known and unknown causes, and I freely assume those risks.
Known complications could include, but are not limited to:
Redness, swelling/edema, itching, pain or pressure lasting more than one week
Nodules or induration at the injection site
Discoloration of the injection site
Poor effect
Allergic reactions
The effects of BOTOX are apparent 2-5 days after treatment
The effects of BOTOX usually last 4-6 months. Periodic re-treatment will be necessary to maintain the effects of BOTOX
Repeated treatment may lead to permanent loss of muscle tone in the treated area
Bruising
Facial asymmetry
Paralysis leading to droopy eyelid and double vision
Some patients may experience weakness and/or flu-like symptoms
Some patients may develop antibodies to BOTOX
I certify that I have none of the known conditions that would contraindicate treatment. These conditions include hypertrophy scars, a history of any autoimmune disease, or immune therapy. I am not pregnant, breast-feeding, and I have no known allergy to BOTOX.
I understand this informed consent is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assigns.
I agree that any picture taken of my treatment site may be used for publication and teaching purposes, however, my name will not be disclosed and complete confidentiality of my name will be maintained.
I understand that no guarantee, warranty or assurance has been made as to the treatment results.
I understand that the results are of temporary nature, and more treatments will be needed to maintain improvement.
I agree to adhere to all safety precautions described, including those below:
No laying down or reclining for four hours after injection
No scratching or rubbing injected area
No bending forward for four hours
Make up should be avoided for one or two hours after injection.
I certify that I have read this entire informed consent and that I understand and agree to the information stated in this form.
I consent to allowing Mirage Salon & MedSpa permission to use the photographs on their social media for promotional purposes.