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Botox Consent Form
- To the patient: Being fully informed about your condition and treatment will help you make the decision whether or not to undergo BOTOX® Cosmetic treatment. This disclosure is not meant to alarm you; it is simply an effort to better inform you so that you may give or withhold you consent for this treatment.

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BOTOX®

WHAT IS BOTOX® COSMETIC?

BOTOX® Cosmetic is a simple, non-surgical,
physician-administered treatment that can temporarily smooth moderate to severe frown lines between the brows in people from 18 to 65 years of age. It is the only treatment of its type approved by the Food and Drug Administration (FDA).

One 10-minute treatment—a few tiny injections—and within days there's a noticeable improvement in those persistent lines between the brows, which can last up to 4 months. Results may vary.

BOTOX® Cosmetic is a purified protein produced by the Clostridium botulinum bacterium, which reduces the activity of the muscles that cause those frown lines between the brows to form over time.

A million people have been treated with FDA-approved BOTOX® Cosmetic. There's only one BOTOX® Cosmetic. Talk to your doctor to see if BOTOX® Cosmetic is right for you!

BEFORE AND AFTER RESULTS

A million people have been treated with BOTOX® Cosmetic since FDA approval in 2002. Not just models and movie stars, but people from all types of professions. BOTOX® Cosmetic can smooth moderate to severe frown lines between your brows for up to 4 months. Of course, we know that seeing is believing. So, take a look at men and women who have had BOTOX® Cosmetic treatments, and see for yourself!

TIP: If you're planning on trying BOTOX® Cosmetic, you might want to take pictures of yourself before your first treatment. Then a week later, take new pictures so you can see the results. Your doctor might even do this as part of the procedure. Chances are, you'll like what you see!

Results may vary.

Results may vary.

SIDE EFFECTS OF BOTOX® COMESTICS

Do not use BOTOX® Cosmetic if you:
• have an infection where BOTOX® Cosmetic will be injected
• are allergic to any of the ingredients in BOTOX® Cosmetic
• are pregnant or think you might be pregnant

What should I tell my doctor before using BOTOX®Cosmetic?
Only your doctor can decide if BOTOX® Cosmetic is right for you. Before starting treatment, tell your doctor if you:
• have any diseases that affect your nerves and muscles. These diseases may increase your chance of side effects with BOTOX® Cosmetic treatment.
• are breastfeeding
• are planning to become pregnant soon.

Can any of my medicines interact with BOTOX® Cosmetic?
Be sure that your doctor knows the names of all the medicines you are using, including:
• antibiotics used to treat infections, such as gentamicin, tobramycin, clindamycin, and lincomycin
• medicines used to treat heart rhythm problems, such as quinidine
• medicines used to treat different conditions, such as myasthenia gravis or Alzheimer’s disease.

As with all prescription medicines, you should also notify your doctor if you are taking any over-the-counter medicines or herbal products. This is not a complete list of medicines that can interact with BOTOX® Cosmetic. Ask your doctor or pharmacist for the Professional Package Insert for complete information.