Dermatology of Seattle

13610 First Avenue South, Seattle, WA 98168

206-248-5020 – 206-244-8425 (fax)

CONSENT TO BOTULINUM TOXIN TREATMENT FOR FACIAL WRINKLES

Rationale

I am aware that when a small amount of purified botulinum toxin (BOTOX) is injected into a muscle it causes weakness or paralysis of that muscle. This appears in 3-4 days and usually lasts 4 months but can be shorter or longer.

Frown lines between the eyebrows are due to contraction of small muscles around them between the eyebrows. Injecting BOTOX into this area will paralyze or weaken these muscles causing temporary improvement or disappearance of the frown lines. Similarly, crow’s feet and horizontal forehead lines can also be improved by the injection of BOTOX into this area which will weaken the muscles and cause improvement in wrinkles in this area.

Results and Postoperative Care

(1) I understand that I will not be able to “frown” while injection into this area is effective but that this will reverse itself after a period of months at which time retreatment is appropriate.

(2) I understand that I must stay in the erect posture and that I must not manipulate the area of the injection for 3-4 hours post-injection.

(3) I understand that it would be advantageous for me to forcibly and repeatedly use the treated muscles in the 3-4 hours post-injection to get a better result.

Risks and Complications

BOTOX treatment of frown lines can cause minor temporary droop of one eyelid in less than 3% of injections. This usually lasts 2-4 weeks. Occasional numbness of a small area on the forehead lasting 2-3 weeks, bruising and transient headache have also occurred.

In a very small number of individuals the injection does not work as satisfactorily or for as long as usual.

Photographs

I authorize the taking of clinical photographs and their use for scientific purposes both in publications and presentations. I understand my identity will be protected.

Pregnancy and Neurologic Disease

I am not aware that I am pregnant nor that I have any significant neurologic disease.

Payment

I understand that this procedure is cosmetic and that payment is my responsibility and due prior to treatment.

I have read the above and understand it. My questions have been answered satisfactorily by the doctor. I accept the risks and complications of this procedure.

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Patient Date

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Witness Date