I understand that the purpose of this procedure, (select Dysport, Botox, Xeomin, Jeaveau), is for facial wrinkles, lip flip, platysma bands, and correcting asymmetry from facial paresis, otoplasty and nasal valve repair. There are several alternatives to treatment including, but not limited to laser treatments, chemical peels, facial rejuvenation or no treatment at all.

RISKS AND COMPLICATIONS that may be associated with the injection of botulinumtoxinA (DYSPORT OR BOTOX) include, but are not limited to:

Headaches: I understand that headaches are possible and usually last one day but may persist longer in a very small percentage of patients.

Injection Site Bruising: I understand that bruising in soft tissues is possible as a result of the needle puncture of the skin. Bruising can last for several hours, days, weeks, months, and in rare cases, the effect of bruising could be permanent.

Facial Paresis (eyelid ptosis): I understand that local weakness of the injected muscles is the expected pharmacological action of botulinuptoxinA and weakness of adjacent muscles may occur which may result in....

using medications that can prolong bleeding, such aspirin,??? or certain vitamins and supplements may experience increased bruising or bleeding at the injection site.

Eye Disorder: I understand that injections of botulinumtoxinA may cause reduced blinking or effectiveness of blinking, and that I should seek immediate medical attention if eye pain or irritation occur following treatment. An inability to blink the eyelids normally may result in corneal exposure and has been associated with damage to the eye as imparied vision or double vision, which is usually temporary. The reduced ability to blink has been associated with corneal ulcerations. These side effects can last for several weeks or longer.

Infection: As with all transcutaneous procedures, I understand the injection of any material carries the risk of infection.

Hypersensitivity: BotulinumtoxinA is contraindicated in patients with a known hypersensitivity to the active substance botulinum toxin type A or to any of the components in the formulation such as human serum albumin. Hypersensitivity reactions have been reported with botulinum toxin products (anaphylaxis, serum sickness, urticaria, soft tissue edema, dyspnea).

Swallowing and Breathing Difficulties: I understand that treatment with botulinumtoxinA and other botulinum toxin products can result in swallowing or breathing difficulties may be more susceptible to these muscles in the area of injection that are involved in breathing or swallowing. These reactions can occur within hours to weeks after injection with botulinumtoxin. Seek immediate medical care if swallowing, speech, or respiratory disorders arise.

Pregnancy and Nursing: There are no adequate and well controlled studies of botulinumtoxinA in pregnant or nursing women.

No studies of interactions of botulinumtoxinA with other drugs or substances or implants have been conducted.

I understand the above list is not meant to be inclusive of all possible risks associated with botulinumtoxinA as there are both known and unknown side effects and complications associated with any medication. I understand that medical attention may be required to resolve complications associated with my injection.

I confirm that I have discussed the potential risks and benefits of botulinumtoxinA with my doctor and that my doctor has satisfactorily answered all of my questions.  I understand there is no guarantee of any particular results of any treatment. I understand the results of treatment with botulinumtoxinA are temporary. Results are not guaranteed.

I acknowledge that I am not pregnant or possible pregnant, lactating or nursing.