Neurotoxin Consent Form
Botox®, Dysport™ and Xeomin® work by relaxing the muscles of facial expression which cause lines, horizontal forehead lines and crow’s feet. The goal is to smooth out facial lines and wrinkles to give you a more youthful and pleasant appearance. Botox® and Dysport™ do not reduce facial lines or wrinkles caused by aging, heredity, gravity or sun damage.
Botox®, Dysport™ and Xeomin® are a purified form of the botulinum toxin. It has been used for more than a decade in children and adults to improve muscle spasms of the facial muscles. Although Botox® was approved by the FDA for cosmetic use in 2002, the use of Botox® for wrinkles is not covered by insurance and must be paid for by the patient.
Response is usually seen 2-14 days after injection. Treated facial muscles become relaxed for an average of 3-5 months, at which point the muscle action (and wrinkles) will return. Botox®, Dysport™ and Xeomin® may be used in addition to, or in place of other cosmetic procedures. Repeated treatment will relax the muscles and soften the lines again.
Our treatment philosophy is to use the minimum effective amount of Botox®, Dysport™ and/or Xeomin® to achieve the desired effect. At times, an additional session may be needed to fully complete the treatment. The fee for Botox® and Dysport™ treatment is based upon the actual number of units used.
Risks and Complications:
Botox®, Dysport™ and Xeomin® are very safe and are commonly used in much larger doses in other fields of medicine. No long-term side effects have been described with cosmetic use of Botox®, Dysport™ and Xeomin®. Side effects are always possible, including the potential for unknown side effects.
The following side effects have been reported and can occur:
Temporary eyelid drooping or double vision
Burning and/or pain at injection site
Bruising, swelling, and/or hematoma
Headache and flu-like symptoms
Migration to non-target areas
Twitching, itching and/or numbness at injection site
Facial asymmetry (unevenness)
Discoloration and/or scab/scar formation
Incomplete or no response
Skin, respiratory or other infection
Unknown or unreported side effects
May cause birth defects in pregnant women
Muscle and tissue damage
Known significant risks have been disclosed including the potential for unknown complications. I understand that I am at a higher risk for side effects if I do not follow the aftercare instructions.
Limitations and Alternatives:
Botox®, Dysport™ and Xeomin® therapy do not treat or cure the underlying cause or disease of facial wrinkles. Rather it is designed to treat dynamic facial lines caused by facial muscle activity. Treatment may be effective for variable lengths of time, may not work as well or as long as expected, or may not work at all. Lines at rest may or may not improve with this treatment. No promises or guarantees have been made in response to either positive or negative outcomes.
By registering, paying and attending the AESTRA Institute course, I understand that I may be photographed, filmed or videotaped and you expressly give the AESTRA Institute, its owners, agents and principals the right to take pictures and/or recordings of me and use my likeness, image, photo without compensation, for broadcast, display, and exhibition in any medium for purposes of advertisement and education and to put the finished pictures/recordings to any use without limitation. I further expressly release AESTRA Institute from any or all claims or actions arising out of or resulting from any use of my image. However, the AESTRA Institute shall not be obligated to use my image.
***By consenting to this treatment, I agree, affirm and represent that I am waiving my right to seek any recovery for any damages that occur as a result of receiving this treatment whether such damages are as the result of an inherent risk or latent or unintended risk and including any damages that may occur which are not the result of a known or expected risk. I waive any and all recovery for damages of any kind what so ever.***
I have been informed and I understand that the practitioners who will perform this procedure may or may not be licensed to practice in the state of Florida. I have been informed and understand that Aestra Institute and Denise Merdich have not reviewed or investigated whether the practitioners performing this procedure have appropriate licensure within the state of Florida. Despite knowing that the practitioner(s) performing my procedure may or may not be licensed in Florida, I am voluntarily giving consent for the practitioners who may be licensed in other states to practice medicine, nursing, advanced registered nurse practitioners and physician's assistants to perform the procedure on me.
Thank you for your Consent Form