Consent for Use of BOTOX® and DYSPORT®
Botox® or Dysport® are purified proteins that can be injected into a muscle to cause temporary weakness or paralysis of that muscle. Botox® and Dysport® are indicated for the temporary improvement in the appearance of moderate to severe expression wrinkles. The results appear in 2-14 days, depending on the individual, and usually last about 3-4 months, but can be shorter or longer.

Botox® and Dysport® block neuromuscular transmission by binding to receptor sites on motor nerve terminals. This blocks the release of acetylcholine and renders the muscle unable to contract. Frown lines (vertical lines between the eyebrows) are due to contraction of small muscles in this area. The FDA has approved the use of Botox® and Dysport® to improve these lines/wrinkles between the eyebrows and the wrinkles next to the eyes (Crow's feet). Botox® and Dysport® have NOT been FDA approved for treating or the horizontal lines/wrinkles on the forehead, "bunny nose", dimpled chin, vertical lines around the lips, neck bands, horizontal neck lines, lip augmentation, or "square jaw". However, these areas, in addition to other areas of the face and neck, have been successfully treated with Botox® and Dysport® for many years.

It is important to understand that wrinkles/lines visible at rest (relaxation of the facial muscles), may not improve with the administration of Botox® or Dysport®. Lines/wrinkles visible at rest are more likely to respond to the injection of fillers in those areas.
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The details of the procedure have been explained to me in terms I understand. Alternative methods & their benefits & disadvantages have been explained to me. *
Required
I understand that the FDA has only approved the cosmetic use of Botox® Cosmetic & Dysport® for vertical frown lines between the brows and "Crow's feet". Any other cosmetic use is considered "off label". *
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I understand and am aware of the most likely risks and complications of Botox® and Dysport® injections. Including but not limited to: Paralysis of a nearby muscle that could interfere with opening of eye (s); Local numbness; Headache, nausea, or flu-like symptoms; Swallowing, speech, or respiratory disorders; Swelling, bruising, or redness at the injection site; Disorientation and double vision; Temporary asymmetrical appearance; Abnormal or lack of facial expression; Possible inability to smile when injected in the lower face; Possible inability to purse the lips when injected in the upper lip• Facial Pain; Product ineffectiveness; Desired results are not guaranteed *
Required
Your consent and authorization for this procedure is strictly voluntary. Your signature on this consent form authorizes MagnifaSkin Medspa to use Botox® or Dysport ® (of your choice) for the treatment area you choose. As with any cosmetic procedure, there is no guarantee that you will be completely satisfied. I have read this informed consent form and certify that I understand the contents in full. My signature indicates that I am consenting to receive treatment and have had the opportunity to ask questions about the procedure and it's risk. I have been advised of the risks involved in such treatment and alternative treatments, including no treatment at all. I understand that I release MagnifaSkin Medspa and it's associates, the Medical Supervisor, and Providers from any liability associated with complications from this procedure. *
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