I authorize Dr. Jennifer Rotstein and/or her nurse(s) to perform neurotoxin injections in order to reduce the appearance of my facial wrinkles in the treated areas. I understand that the neurotoxin relaxes the muscles under the skin and therefore reduces the amount of wrinkling caused by muscular contraction. I understand that tiny amounts of neurotoxin will be injected into the muscles under my skin and that this will cause my muscles to temporarily relax for approximately 3-4 months. Although results are commonly predictable and provide a good outcome, I have been informed that the practice of cosmetic medicine is not an exact science and that no guarantees can be made concerning expected results in my case.
I also understand that it can take up to 14 days for the full effect to occur although the benefits may begin to develop within the first few days. I understand that there will be a reduction of muscle movement/wrinkling in the treated areas but that there is no guarantee that wrinkles will completely disappear.
I understand that this procedure is not medically necessary and that there are some potential side effects which include but may not be limited to the following:
- Headaches, swelling, bruising and tenderness in the treated areas;
- Neurotoxin spread resulting in unwanted effects on distant muscles/organs or asymmetry;
- Drooping eyelid or eyebrow or lip;
- Allergy or infection;
I understand that some of these potential side effects may require additional treatments at the discretion of my doctor (for example, eye drops to correct a droopy eyelid) and that these treatments will be my financial responsibility and I consent to the use of such treatments.
I have received post-treatment instructions and I agree to follow the recommendations of my doctor/nurse. Specifically, I will not manipulate the treated area, lie down, or engage in strenuous activity for 4 hours after the injection. I understand that failure to comply with these instructions may result in undesired and unpredictable effects of my treatment.
I understand that I cannot be treated with neurotoxin if I am pregnant, breastfeeding, have a history of hypersensitivity to any neurotoxin, or if I have a history of neuromuscular disease. I understand that I cannot receive Dysport injections if I have a history of allergy to cow’s milk protein.
I agree that this consent constitutes full disclosure.
I consent to the injection of a neurotoxin as selected by my health care professional and as discussed with me.