• Rationale

    I am aware that when small amounts of purified toxin "BOTOX" is injected into a muscle it causes weakness or paralysis of that muscle. This appears in four to fourteen days and usually lasts four months but can be shorter or longer.

    Frown lines between the eyebrows are due to the contraction of small muscles, mainly the corrugators, beneath the inner part of each eyebrow. Injecting "BOTOX" into this muscle will relax it causing improvement or in some cases disappearance of the lines. Botox can be injected into various other muscles in and around the face in order to weaken muscles which may reduce the appearance of lines. I understand that Botox can, and may be used in an “off-label” manner during my treatment session/sessions.

    Results and Postoperative Care

    1. I understand that my ability to move the muscles will be lessened or eliminated while the injection 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 not manipulate the area of the injection for the four hour post-injection period.

    Risks and Complications

    BOTOX treatment of facial lines can rarely cause minor temporary droop of eyelids or heaviness of the brows. This usually lasts two to three weeks. In some cases a lid droop can be severe or result in complete lid closure can last for four months or more. Occasional numbness of the forehead lasting two to three weeks or longer, bruising and transient headache have occurred in a very small number of individuals, the injection does not work as satisfactorily or for as long as usual. Other possible problems that may occur include allergic reaction, infection and poor post injection results.


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

    Pregnancy and Neurologic Disease

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

    Oral Herpes – If I have a history of oral herpes and I am to receive Botox injections around my lips, I have informed the doctor that I have a history of oral herpes.


    Payment is due at the time of treatment. If a "touch up" of the treated area is necessary. This is usually performed at two weeks and there will be an additional charge. I have read and understand the above mentioned information. My questions have been answered satisfactorily by the doctor and the doctor's associates. I accept the risks and complications of the procedure.

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