Patient Informed Consent

BOTOX® Cosmetic
(Botulinum toxin type A)

TO THE PATIENT:

You have the right, as a patient, to be informed about your condition and the recommended surgical, medical, or diagnostic procedure to be used so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give or withhold your consent to the procedure.

OPERATION OR PROCEDURE AND ALTERNATIVES:

I, ______________________________________, (patient or patient’s guardian) authorize Dr. Hans R. Kuisle or Dr. Winfield Hartley, to perform the following operation or procedure:

BOTOX® Cosmetic (Botulinum Toxin Type A):

Treatment of: __________________________________________________ (your name)

_____ I understand the reason for this procedure is: COSMETIC

_____ I understand alternative procedures include: NON-TREATMENT

Potential unforeseen risks of BOTOX® Cosmetic injection may occur. The most common side effects are headache (13.3%), respiratory infection (3.5%), temporary droopy eyelid (3.2%), nausea (3.2%) and flu syndrome (2.0%). Bruising at the injection site(s) and asymmetry of the result may also occur.

BOTOX® Cosmetic treatments may not be effective in all patients. BOTOX® Cosmetic is not permanent, and will need to be repeated to maintain results.

I understand that no guarantee or assurances have been made as to the results of the procedure and that it will not cure the condition.

PATIENT’ S CONSENT:

I have been given an opportunity to ask questions about my condition, alternative forms of treatment, risks of nontreatment, the procedure to be used, and the risks and hazards involved, and I believe that I have sufficient information to give this informed consent. I have read and fully understand the information provided on this procedure and this consent form, and understand I should not sign this form if all items, including all my questions, have not been explained or answered to my satisfaction.