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Forms

MIRAGE Salon & MedSpa

BOTOX Informed Patient Consent Form

Informed Patient Consent for Botulinum Toxin Injection (BOTOX)

Botulinum Toxin Type-A As BOTOX from Allergan

For the temporary treatment of superficial facial wrinkles

Patient Information

SECTION 1: ACKNOWLEDGMENTS AND AGREEMENTS

I, the above mentioned Patient, consent to, and authorize the following selected Provider to perform a treatment of facial wrinkles with BOTOX:
Jami Maxey
Kelly Jueden
Cari Paden
Miranda Lockman
Sonia Chicas
Other

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

SECTION 2: CONSENT

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