Botox in Needham, MA - Carrie Reddish, DMD, P.C.

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Botox Therapy Consent Form

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Please click the "I understand" box for each section to indicate that you understand each topic. Do not click the check mark box if you desire more. information.

Proposed Treatment*

Injection of a very small amount of Botox®, 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.

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Anticipated Benefit*

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

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Anticipated Benefit

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.

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Risks and Complications

Possible side effects include: 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.

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Risks and Complications

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 if 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 with the use of blood thinning medications such as Coumadin. I understand that if I am taking a blood thinning medication, this treatment may result in significant bruising and may not be recommended.

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Risks and Complications

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.

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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 the conditions above apply to me.

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Limitations and Alternatives

Botox® or Xeomin® are best at treating dynamic facial lines, those caused by facial muscle activity; lines present at rest mayor 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. I have been informed of other alternatives which exist for the treatment of wrinkles such as topical creams, chemical peels, laser treatments, surgical removal of the frown muscles, forehead/brow lift, facelift, collagen or hyaluronic acid treatments.

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Cost/Fees

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

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Consent

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.

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Please make sure to click SUBMIT

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