Celebrity Cosmetic Dermatologist

Botox Treatment Consent Form

Prime HealthAddress: 1035 Sterling Rd, Suite 104, Herndon, VA 20170Physician Name: Dr. Han Tonthat

1. Purpose of this Consent

By signing this form, I confirm that I have been informed about the Botox procedure, its potential benefits, risks, and side effects. I voluntarily agree to undergo treatment with Botox (Botulinum Toxin Type A) for aesthetic purposes.

2. Description of the Procedure

Botox is an injectable neuromodulator that temporarily reduces the activity of muscles responsible for dynamic wrinkles, such as:

• Frown lines (glabellar lines).

• Forehead wrinkles.

• Crow’s feet around the eyes.

• Additional areas as discussed with the practitioner.

The effects are temporary and typically last between 3 to 6 months.

3. Expected Results

• Botox treatment aims to smooth wrinkles and fine lines, creating a more youthful appearance.

• Results are typically visible within 3–14 days after treatment.

• Effects may vary based on individual response, and touch-ups may be required to achieve desired outcomes.

4. Potential Risks and Side Effects

Common Side Effects (Temporary and Mild)

These side effects are relatively mild, typically resolve on their own within a few days, and occur at or near the injection site:

1. Redness: Temporary redness or irritation at the injection site.

2. Swelling: Mild swelling, especially in sensitive areas like around the eyes.

3. Bruising: Caused by small blood vessel trauma during injection; usually resolves within 1–2 weeks.

4. Pain or Tenderness: Temporary discomfort at the injection site.

5. Headaches: Often mild and short-lived.

6. Tightness or Heaviness: A feeling of pressure or heaviness in the treated area.

7. Itching: Mild itching as the injection sites heal.

Less Common Side Effects

These side effects may occur but are less frequent and often resolve with minimal intervention:

1. Asymmetry: Uneven results due to varied muscle response.

2. Drooping Eyelid (Ptosis): Temporary muscle relaxation leading to eyelid droop; may last 2–6 weeks.

3. Dry Eyes: Reduced blinking causing dryness or irritation, especially when treating crow’s feet.

4. Excessive Tearing: Overactive tear glands.

5. Muscle Weakness: Temporary weakness in nearby muscles.

6. Numbness or Tingling: Altered sensation in the treated area.

7. Flu-like Symptoms: Mild fatigue, fever, or body aches shortly after injection.

Rare but Serious Side Effects

These are rare complications that may require medical intervention:

1. Allergic Reactions:

   • Symptoms include hives, swelling, difficulty breathing, or anaphylaxis (life-threatening).

2. Infection:

   • Swelling, redness, or pain caused by infection at the injection site.

3. Migration of Toxin:

   • Botox spreading to unintended muscles, potentially causing unintended paralysis or weakness in adjacent areas.

4. Severe Eyebrow or Eyelid Drooping:

   • Unintended paralysis of muscles controlling these areas.

5. Vision Problems:

   • Blurred or double vision, drooping eyelids, or difficulty focusing.

6. Difficulty Swallowing (Dysphagia):

   • Weakness in throat muscles if Botox migrates to the neck area.

7. Slurred Speech:

   • Muscle weakness affecting articulation.

8. Breathing Issues:

   • Weakness in muscles controlling respiration (very rare, but serious).

Long-Term Risks

Rarely, prolonged or repeated Botox use may result in:

1. Resistance to Botox:

   • Development of antibodies that reduce effectiveness.

2. Chronic Muscle Weakness:

   • Over time, treated muscles may weaken excessively or atrophy.

3. Skin Laxity:

   • Frequent injections may lead to looseness of the skin in treated areas.

Adverse Reactions from Improper Technique

Poor injection technique or product placement may cause:

1. Over-Correction:

   • Too much Botox causing an unnatural, "frozen" appearance.

2. Under-Correction:

   • Insufficient Botox leading to incomplete treatment.

3. Painful Nodules:

   • Small lumps at injection sites due to improper administration.

Systemic Side Effects

Although extremely rare, Botox may cause systemic effects, especially if administered in high doses:

1. Generalized Weakness:

   • Muscle fatigue beyond the treated area.

2. Dizziness or Lightheadedness:

   • Often short-lived but may occur shortly after treatment.

3. Nausea:

   • Mild digestive upset in some individuals.

Psychological or Emotional Effects

Some patients may experience:

1. Dissatisfaction:

   • Due to unmet expectations or differences from anticipated results.

2. Body Dysmorphia:

   • Rarely, patients with pre-existing concerns about their appearance may fixate on perceived flaws.

Extremely Rare and Critical Side Effects

1. Botulism-Like Symptoms:

   • Occurs when the toxin affects unintended areas, causing severe muscle weakness, difficulty breathing, or swallowing.

2. Severe Allergic Reactions:

   • May lead to anaphylaxis, requiring emergency care.

3. Vocal Changes:

   • Weakness in muscles affecting speech or voice quality.

5. Contraindications

I understand that Botox treatment is not suitable for individuals with the following conditions:

• Pregnancy or breastfeeding.

• Neuromuscular disorders (e.g., Myasthenia Gravis, ALS).

• Active skin infections at the treatment site.

• Known allergies to Botulinum Toxin Type A or any components of Botox.

• Current use of aminoglycoside antibiotics, anticoagulants, or other medications that may interact with Botox.

6. Patient Responsibilities

To ensure the best outcomes and minimize risks, I agree to:

1. Provide Accurate Medical History: Disclose all health conditions, medications, and allergies.

2. Follow Pre- and Post-Treatment Instructions:

   • Avoid rubbing or massaging the treated area for 24 hours.

   • Remain upright for 4 hours post-treatment.

   • Refrain from strenuous exercise, alcohol, or heat exposure for 24 hours.

3. Notify the Clinic: Immediately report any unusual symptoms, side effects, or concerns.

7. No Guarantee of Results

I understand that aesthetic outcomes are subjective and may vary. While the procedure is performed with care, Prime Health cannot guarantee specific results, and touch-ups may be necessary for optimal results.

8. Refund Policy

The Patient acknowledges and agrees to the following refund terms:

1. Non-Refundable Services: All fees for completed services are non-refundable.

2. Health-Related Refunds: If treatments are stopped due to verified health issues, refunds will be issued only for unused treatments.

3. Payment Obligations: If enrolled in a payment plan, the Patient must complete all payments, even if they discontinue the program.

9. Emergency Contact

9. Acknowledgment and Consent

By signing below, I confirm that:

1. I have read and understood this Consent Form and its contents.

2. I have been informed of the procedure, risks, and benefits, and had all my questions answered.

3. I understand the risks, including rare but serious complications, and agree to proceed with the treatment.

4. I release Prime Health, its staff, and practitioners from liability for any complications, except those caused by gross negligence or malpractice.