Consent for Use of BOTOX®
BOTOX® is a brand name for botulinum toxin type A, a neurotoxin that blocks muscle
contraction by temporarily inactivating the nerves that control them. The effects of
BOTOX® become apparent 2-5 days after the injection and generally last 3-4 months.
The FDA has approved the use of BOTOx® to treat facial dystonias (spasms),
strabismus (crossed eyes) and to soften facial rhytids (wrinkles). There may be
alternatives to BOTOx® including medicines or surgery.

Unwanted side effects of BOTOx® include but are not limited to:

• Local bleeding
• Bruising
• Undercorrection (not enough effect) or overcorrection (too much effect)
• Facial asymmetry (one side looks different than the other)
• Paralysis of a nearby muscle leading to: droopy eyelid, double vision, inability to
close the eye, difficulty whistling or drinking from a straw
• Generalized weakness
• Permanent loss of muscle tone with repeated injection
• Flu-like syndrome
• Development of antibodies to BOTOX®
• Infection

BOTOX® contains Human-derived albumin and carries a theoretic risk of virus
transmission. There have been no reports of disease transmission through BOTOx®. If
you are pregnant, nursing or are allergic to albumin (eggs), you should not receive
injections. Patients taking aminoglycoside antibiotics, or with Eaton-Lambert syndrome,
Lou Gehrig's disease or myasthenia gravis should not have BOTOX® .
I understand the above and have had the risks, benefits and alternatives explained to me. I give my informed consent for BOTOX® injections today. *
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