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Neurotoxin Consent Form: Botox, Dysport, Jeuveau, and Xeomin

lip filler injections

"Botox" is one of the most familiar brands of botulinum toxin injections. Botulinum toxins are neurotoxins that impact nerves, leading to muscle weakening. These injections serve both cosmetic and medical purposes. Practitioners administer small quantities of botulinum toxin into specific areas to reduce wrinkles, prevent migraines, and manage a broad spectrum of other health conditions.

Botox works by blocking nerve signals to muscles, resulting in the temporary inability of the injected muscles to contract. This effect typically lasts for about three to four months. The specific muscles that are injected depend on the areas of concern, and it's possible to treat multiple areas during a single session.

RISKS & COMPLICATIONS

For every treatment, there are inherent risks involved. It is crucial that you thoroughly comprehend these risks before proceeding with the treatment. While providing a complete medical history can help reduce these risks, there may still be unforeseen complications that may arise. If you have any concerns about these risks, do not hesitate to reach out to your healthcare professional.

The potential risks and complications include:

  • Infection

  • Bruising

  • Eye dryness or tearing

  • Swelling

  • Headaches

  • Anaphylaxis

  • Scarring of the skin

  • Increased sensitivity

  • Blurred vision

  • Skin irritation

  • Allergic reaction

  • Ptosis of treated area

It's essential to consult with a qualified healthcare provider to address any concerns and assess your individual risk factors before undergoing any treatment.

In rare cases, botulinum toxin may extend beyond the intended treatment area, resulting in botulinum-like signs and symptoms. These may include breathing difficulties, trouble swallowing, muscle weakness, and slurred speech. If you experience any of these unusual symptoms following treatment, it is imperative to seek immediate medical attention.

*Please read each statement*

 

During the course of the treatment, despite all precautionary measures taken by the technician, it's important to recognize that there is a possibility of injury. I will not hold the technician responsible for any issues that may arise as a result of undergoing the procedure.

 

I understand that there are inherent risks associated with botulinum toxin/Botox. If I experience any form of adverse reaction, I will promptly seek medical attention and inform my technician.

 

It is my responsibility to communicate any concerns I may have to the technician before the procedure.

 

I understand and agree to follow the aftercare instructions provided by my technician. I am aware that not adhering to the aftercare instructions may impact the achievement of the desired results.

 

I acknowledge that the product will be injected into the muscles of my face as part of the botulinum/Botox process. The technician performing the procedure will not be held liable for any damages to my skin or me for any reason, especially if I fail to follow aftercare instructions.

 

I have disclosed all pertinent medical history, and I commit to informing my technician of any changes that may occur in the future.

By signing below, I hereby acknowledge that I have read and understand all the information in this informed consent agreement. I understand that this agreement is legal and binding and will remain in effect for this procedure and all future follow-ups conducted by Austin Aesthetic Couture Inc and any of their associates. I fully understand the risks and side effects associated with the treatment. I freely assume these risks and release Austin Aesthetic Couture and any of their associates of all liability.

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Austin Aesthetic couture inc.

CONTACT

14005 US-183

Unit 100

Austin, TX 78717

United States

830-310-2401

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