State-of-the-art, personalized skin care
from experienced professionals

Rationale: I am aware that when a small amount of purified botulinum toxin (“BOTOX”) is injected into a muscle it causes weakness or paralysis of that muscle. This appears in 3-4 days and usually lasts four months but can be shorter or longer.

Frown lines between the eyebrows are due to contraction of a small muscle, corrugator, beneath the inner part of each eyebrow. Injecting “BOTOX” into this muscle will paralyze it causing improvement or disappearance of the frown lines.

Results and Postoperative Care:

  1. I understand that I will not be able to “frown” while the injection is effective but that this will reverse itself after a period of months at which time re-treatment is appropriate.
  2. I understand that I must stay in the erect posture and that I must not manipulate the area of the injection for the 4 hour post-injection period.

Risks and Complications: BOTOX treatment of frown lines can cause a minor temporary droop of one eyelid in approximately 2% of injections. This usually lasts no longer than 4-6 weeks. Occasional numbness of the forehead lasting 2-3 weeks, bruising and transient headache have occurred. In a very small number of individuals, the injection does not work as satisfactorily or for as long as usual. Patients may experience a vasovagal response, “passing out” after or during the procedure. (Please alert your doctor if you have ever had this occur.)

Warnings and Precautions: Serious and/or immediate hypersensitivity reactions have been rarely reported. These reactions include anaphylaxis, urticaria, soft-tissue edema, and dyspnea. There have been rare reports of adverse events involving the cardiovascular system, including arrhythmia and myocardial infarction, some with fatal outcomes. Some of these patients had risk factors including pre-existing cardiovascular disease. Patients with neuromuscular disorders such as ALS, myasthenia gravis, or Lambert-Eaton syndrome may be at increased risk of serious adverse events. New onset or recurrent seizures have also been reported, typically in patients who are predisposed to experiencing these events. The exact relationship of these events to the botulinum toxin injection has not been established.

Adverse Reactions: The most common adverse events following injection include blepharoptosis and nausea. Localized pain, infection, inflammation, tenderness, swelling, erythema, and/or bleeding/bruising may be associated with the injection.
Pregnancy and Neurologic Disease: I am not aware that I am pregnant nor that I have any significant neurologic disease.

Payment: I understand that this procedure is cosmetic and that full payment today is my responsibility.
I certify that I have read and understand the contents of this consent form. I have been given the opportunity to ask the doctor/staff any questions that I have about the procedure, and all of my questions have been answered. The doctor/staff has explained the procedure and its alternatives to me, and I both understand and accept the risks involved in this procedure.

Please download this PDF form to sign.

 


 

Petaluma Office
165 Lynch Creek Way
Petaluma, CA 94954
 M-F, 8:00am-5:00pm
(707) 762-5531
Fax: (707) 762-5976

 

 

Hercules Office
500 Alfred Nobel Dr., Ste. 245
Hercules, CA 94547
M-F, 8:00am-5:00pm
Open Saturday for aesthetic services
 (510) 741-7418
Fax: (510) 741-7456

 

Billing office
phone: 510-741-7299
fax: 510- 741-7493

 




At Dermatology Associates of the Bay Area, our board-certified dermatologists serve patients at our Petaluma and Hercules offices. We are committed to the highest standards, and we offer a full range of cosmetic, medical, and surgical dermatology procedures, as well as quality skin care products.

Dermatology Associates of the Bay Area
165 Lynch Creek Way | Petaluma, California 94954 | Phone: (707) 762-5531 | Fax: (707) 762-5976
500 Alfred Nobel Drive, Suite 245 | Hercules, California 94547 | Phone: (510) 741-7418 | Fax: (510) 741-7456