Neurotoxins Consent Form

Neurotoxins Consent
Name
Name
First Name
Last Name

Informed Consent for Botulinum Toxin Type A (Neurotoxin / Neuromodulator) Injections

This consent form is intended to confirm that I have been adequately informed, educated, and counseled regarding FDA-approved botulinum toxin type A injections, including their purpose, potential benefits, alternatives, limitations, risks, and possible complications, so that I may make an informed decision regarding treatment.

Treatment History

I acknowledge that if I have previously received botulinum toxin injections, I have disclosed the relevant dates, products used, and injection sites to my provider.

Nature of the Procedure

  • I understand that botulinum toxin type A is injected into specific muscles to cause temporary muscle relaxation, which may temporarily improve the appearance of facial expression lines, including but not limited to frown lines, crow’s feet, forehead lines, and other facial areas.
  • I understand that FDA-approved botulinum toxin products include Botox® (onabotulinumtoxinA), Dysport® (abobotulinumtoxinA), Xeomin® (incobotulinumtoxinA), Jeuveau® (prabotulinumtoxinA), and Letybo® (letibotulinumtoxinA).
  • I understand that Botox® and Xeomin® are FDA-approved for frown lines, crow’s feet, and forehead lines, and that Dysport®, Jeuveau®, and Letybo® are FDA-approved for frown lines.
  • I understand that injection into other anatomical areas constitutes off-label use, which is common, legally permissible, and within the accepted standard of medical practice.
  • I understand that the procedure involves the use of a fine needle to inject botulinum toxin into targeted muscles.

Expected Results & Treatment Course

  • I understand that visible improvement generally begins within 3–10 days, with maximal effect typically seen by approximately 14 days.
  • I understand that individual response varies. If results are not satisfactory after approximately 10–14 days, I may contact the clinic for re-evaluation. I understand that touch-up treatments may require additional units and may incur an additional fee, depending on muscle strength and response.
  • I understand that results are temporary and that repeat treatments are typically required every 3–4 months to maintain results.
  • I understand the distinction between initial corrective treatment and maintenance treatment, which may occur every 4–6 months depending on individual response.
  • I understand that medicine is not an exact science and that no specific result can be guaranteed, either expressed or implied.

Alternatives & Voluntary Decision

  • I understand that alternative treatments exist, including no treatment, and that these options have been discussed with my provider.
  • I confirm that I have had the opportunity to ask questions, conduct independent research, and review educational resources, including manufacturer-provided information if desired.

Medical Disclosure & Contraindications

  • I agree to fully disclose all medical conditions, allergies, and medications, including supplements.
  • To the best of my knowledge, I do not have an allergy to botulinum toxin type A or cow’s milk protein.
  • I deny that I am currently pregnant, attempting to become pregnant, or breastfeeding. I understand that the safety of botulinum toxin during pregnancy or breastfeeding has not been established, and animal studies suggest potential fetal risk.
  • I deny having any neuromuscular disorders, including but not limited to amyotrophic lateral sclerosis (ALS), myasthenia gravis, or Lambert-Eaton syndrome.

Risks & Possible Complications

I understand that all injections carry risk. Potential risks include, but are not limited to:

  • Discomfort at injection sites
  • Bleeding or bruising, which may be increased by alcohol or anti-inflammatory medication use
  • Infection (rare)
  • Scarring (rare)
  • Temporary weakening of adjacent muscles, including eyelid droop (ptosis) or eyebrow asymmetry
  • Temporary blurred vision due to muscle weakness
  • Allergic reactions
  • Unknown or unforeseen effects

I understand that most effects are temporary and resolve within approximately three months.

I understand that, in very rare cases, botulinum toxin may spread beyond the injection site and cause serious symptoms, including muscle weakness away from the injection site, double vision, hoarseness or voice changes, difficulty speaking clearly, difficulty swallowing or breathing, and loss of bladder control. I understand that these symptoms require immediate medical attention and that I must notify the clinic promptly.

Post-Treatment Responsibility

  • I understand that individual experiences vary and that delayed reactions may occur.
  • I agree to promptly notify AI Wellness Center of Excellence of any unexpected symptoms, complications, or concerns and allow the clinic an opportunity to evaluate and participate in care when reasonably possible.

Authorization

  • I hereby authorize Dr. Gideon Kwok, D.O., and/or trained and qualified licensed medical providers acting within their scope of practice to perform botulinum toxin type A injections.
  • I acknowledge that I have had the opportunity to inquire about the qualifications and experience of the provider performing my treatment and that I am satisfied.
  • I affirm that my consent is voluntary, informed, and freely given.

Final Acknowledgment

I acknowledge that I have read and fully understand this consent form, that all disclosures have been explained to me, that I have had the opportunity to ask questions, and that this form supersedes any prior verbal or written disclosures. I freely consent to botulinum toxin type A injections.