Botox Patient Consent Form

I, , hereby request to have Botox® injections by Dr. John Spillane.

I have been instructed that the material risks in this procedure includes loss of lines and wrinkles, drooping (ptosis) of the mouth, eyebrow and/or eyelid ; bruising, pain, headaches, bleeding, tenderness, swelling, redness at injection sites; allergic reactions, infection; numbness, tingling, paralysis or partial paralysis; loss of facial expressions, loss of blood and scarring, disfiguring scars; cardiac arrest, brain damage, death. There may also be other unspecified risks and unknown long-term risks.

I have been informed that I should seek immediate medical attention should I notice the following effects after administration of botulinum toxins: dysphagia (difficulty swallowing), dysphonia (difficulty speaking), weakness, dyspnea (difficult breathing) I am aware that these effects may occur early as one day and as late as several weeks after treatment.

The indication that I am being treated for, TMD symptoms and related tension headaches, is not printed on the label of the Botox vial. This treatment has been accepted for a therapeutic indication. I am aware that the outcome is often unpredictable and may not be to my satisfaction.

I realize that during the course of this procedure other conditions may arise or may have to be treated and I hereby consent to any additional procedure or treatment which the healthcare provider deems necessary or appropriate to treat such conditions.

I also understand that treatment may be ineffective or have a limited duration of effect.

By checking this box, you agree to the above declaration

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