Botox Injection Consent Form

Botox therapy is an injection treatment designed to reduce facial expression lines and to smooth jaw lines. It also used to reduce the effect of grinding or to reduce the elevation of upper lip for those who have high smile line by injecting to the responsible muscles. Botox is trade name for botolinum purified protein complex. Once injected, it weakens the muscles which results in reducing the contraction of those muscles. The effect can be noticed within 2-4 weeks. Botox therapy is temporary, meaning it will be removed by body within 3-5 months after injection and it can be repeated accordingly. Individual response can be varied from one to the other depends of many factors like depth of lines, size of muscles and the amount of injection.

Botox injections are customized for every patient, depending on his or her particular needs. These can be performed in areas involving the eyelid region, forehead, and jaw line. Botox cannot stop the process of aging. It can however, temporarily diminish the look of wrinkles caused by muscle groups. Botox injections may be performed as a singular procedure or as an adjunct to a surgical procedure or filler injection. Botox cannot remove / fill the existing lines at relax mode in which fillers can be used to fill these lines.

ALTERNATIVE TREATMENTS: Alternative forms of management include not treating the skin wrinkles by any means, injection of dermal fillers, plastic surgery and laser, etc. Use of dental appliances in place or in adjunction to, for patients who receive Botox injection in masseter muscle, is recommended.

RISKS of Botox Injections: Some complications may arise after Botox injection. These are including but not limited to: reduction in mastication power in masseter muscle injection, bleeding and bruising, crossed eyes due to post-injection bleeding, dry eye and corneal exposure, damage to deeper structures, migration of Botox from its original injection site to other areas and produce temporary paralysis of other muscle groups or other unintended effects, drooping eyelid, double vision, blindness, facial asymmetry, pain and discomfort, allergic reaction, infection, presence of antibodies, skin rash and itching, poor response or long term unknown risks. Aspirin, anti-inflammatory medications, platelet inhibitors, anticoagulants, Vitamin E, ginkgo biloba, and other “herbs / homeopathic remedies” may contribute to a greater risk of a bleeding problem.  Do not take these for ten days before or after Botox injections. Patients with peripheral motor neuropathic disorders (amyotrophic lateral sclerosis, myasthenia gravis, motor neuropathies) may be at greater risk of clinically significant side effects from Botox. . It is not recommended that pregnant women or nursing mothers receive Botox treatments. The effect of Botox may be potentiated by aminoglycoside antibiotics or other drugs known to interfere with neuromuscular transmission. Should complications occur, additional surgery or other treatments may be necessary. The practice of medicine and surgery is not an exact science. Although good results are expected, there is no guarantee or warranty expressed or implied, on the results that may be obtained.

FINANCIAL RESPONSIBILITIES: Most health insurance companies exclude coverage for Botox, cosmetic surgical procedures and treatments or any complications that might occur from the same. Please consult your health insurance provider for detail and eligibility. The cost of Botox injection is based on the number of units of Botox you receive for each site. The fees charged for this procedure do not include any potential future costs for additional procedures that you elect to have or require in order to revise, optimize, or complete your outcome.  Additional costs of medical treatment would be your responsibility should complications develop from Botox injections. In signing the consent for this procedure, you acknowledge that you have been informed about its risk and consequences and accept responsibility for the clinical decisions that were made along with the financial costs of all future treatments.

DISCLAIMER: The informed-consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances. However, informed consent documents should not be considered all-inclusive in defining other methods of care and risks encountered. Informed-consent documents are not intended to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve. It is important that you read the above information carefully and have all of your questions answered before signing the consent.

CONSENT: I agree that I have read and understand the above information. My questions have been fully answered to my satisfaction, and I have made an informed decision to receive Botox injection by certified practitioner at ABAN Dental Centre. I understand the practice of Botox therapy for wrinkles and lines is not an exact science, and that result cannot be guaranteed.