This is an informed consent document that has been prepared to help inform you concerning
DYSPORT® injections, its risks, and alternatives treatments(s).
It is important that you read this information carefully and completely. Please discuss any questions you
may have with your provider. Once you have read and understood this information, and had any
questions addressed to your satisfaction, please sign and date this consent.

DYSPORT® injections involve a series of small subcutaneous injections designed to weaken certain
muscles that cause skin wrinkling. Weakening of the injected muscles begins to be apparent after 2-3
days with the peak effect being reached after 7-14 days. Results can last 3-6 months. The procedure
can be repeated after 3 months; however, injections given at less than 3 month intervals may not
produce a noticeable effect.

Alternative forms of non-surgical and surgical management for the appearance of wrinkles and lines in
the skin include laser ablation, chemical peels, dermal filler, minimally invasive procedures and face lift.
Alternative forms of treatment are all associated with certain risks.

Every procedure involves a certain amount of risk, and it is important that you understand the risks
involved. An individual’s choice to undergo a procedure is based on the comparison of the risk to
potential benefit. Although the majority of patients do no experience these complications, you should
discuss each of them with your provider to make sure you understand the risks, potential complications,
and consequences of DYSPORT® injections.
-Bleeding It is possible, though unusual, to experience localized bleeding
episode during or after the procedure at the site(s) of injection.
Do not take any aspirin or anti-inflammatory medications
for ten days prior to your DYSPORT® injection
-Bruising Following this procedure, it is not uncommon to bruise at the
injection site. Bruising usually resolved in 3-4 days.
-Infection Infection is unusual. Should an infection occur, additional
treatment including antibiotics may be necessary.
-Unsatisfactory Results You may be disappointed with the results of the procedure. The
procedure may result in unacceptable visible deformities, loss of
function and/or loss of sensation.
-Allergic reactions In rare cases, local allergies to botulinum toxin A preparations
(including DYSPORT®) have been reported. Systemic reactions,
which are more serious, may result from any medication or
substance used during the procedure. Allergic reactions may
require additional treatment.
-Drooping of the eyelids
This is a rare but transient complication occurring in 1-2% of
patients. The incidence can be minimized by positioning post
injections. Ptosis usually resolves within several weeks but may
take longer.

-Additional Procedures
Should complications occur, other treatments may be necessary.
Even though risks and complications occur infrequently, the risks
cited are the ones that are particularly associated with DYSPORT®
injections. Although good results are expected, there cannot be
any guarantee or warranty expressed or implied with regard to the
results that may be obtained.

Informed consent documents are used to communicate information about the proposed treatment
of a disease or condition along with disclosure of risks and alternative forms of treatment(s).
The informed consent process attempts to define principles of risk disclosure that should generally
meet the needs of most patients in most circumstances. However, informed consent documents
should not be considered all inclusive in defining other methods of care and risks encountered.
Informed consent documents are not intended to define or serve as the standard of medical care.
Standards of medical care are determined on the basis of all of the facts involved in an individual
case and are subject to change as scientific knowledge and technology advance and as practice
patterns evolve.

It is important that you read the above information carefully and have all of your questions
answered before signing this consent.
I have read the foregoing consent and hereby confirm that I have
1) had each item explained to
2) was given an opportunity to ask questions, and 3) had all of my questions answered. I
hereby authorize the technician to perform the procedure of DYSPORT® injections.
I hereby release my technician, the facility and the doctor from liability associated with this
Patient's Name *
Email *
Date *

I have explained the treatment/procedure(s) stated on this form, including the possible risks,
complications, alternative treatments (including non-treatment) and anticipated results to the patient
before the patient consented.
Injector's signature
1 point
Medical Doctor
1 point
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