Informed Consent for Botox Administration

Informed Consent for Botox^® Administration

I, (patient’s surname, first name, patronymic/middle name)

born on________________________,

residing at:______________________,

contact phone number:______________

give my consent to undergo the procedure of Botox^® administration for cosmetic purposes,

performed by the physician (physician’s surname, first name, patronymic/middle name)

Physician’s contact phone number:______

I confirm that I have been informed about the course of the procedure and the product to be used.

Botox^® is intended for the correction of facial expression lines and is administered by intramuscular injection.

Botox^® injections must be performed by a qualified physician who has completed special training and holds the appropriate authorization from the manufacturing company. The injections may be performed on an outpatient basis in a treatment room.

The use of Botox^® for the correction of vertical glabellar lines is not recommended in patients under 18 years of age or over 65 years of age.

Contraindications

I have been informed of the list of contraindications to the administration of Botox^®.

General contraindications:

• confirmed hypersensitivity to any component of the product;
• inflammation at the intended injection site or sites;
• acute phase of infectious diseases;
• pregnancy and lactation.

For the treatment of blepharospasm and correction of facial muscle activity:

• pronounced gravitational ptosis of the facial soft tissues;
• pronounced herniation in the upper and lower eyelid area.

Botox^® should be used with caution in the following cases:

• in cases of pronounced facial asymmetry;
• in cases of ptosis, dermatochalasis, or deep scars;
• in patients with thick, dense skin or when vertical glabellar lines do not show significant smoothing during mechanical stretching of the skin.

Adverse Reactions

I have been informed of the list of adverse reactions that may occur when Botox^® is used for the correction of facial expression lines.

Adverse reactions associated with the correction of facial expression lines:

• nervous system disorders: headache, paresthesia;
• eye disorders: ptosis;
• gastrointestinal disorders: nausea;
• skin disorders: erythema, a sensation of skin tightness;
• musculoskeletal system disorders: muscle weakness;
• general disorders and administration site reactions: facial pain, swelling at the injection site, ecchymosis, pain at the injection site, skin irritation at the injection site.

The frequency of adverse reactions is 1–10%.

I have been warned that if any side effect becomes more pronounced, or if a side effect not listed here occurs, I should immediately contact my attending physician.

Interaction with Other Medicinal Products

When used concomitantly, the effect of Botox^® may be potentiated by aminoglycoside antibiotics, erythromycin, tetracycline, polymyxins, and agents that reduce neuromuscular transmission, especially curare-like muscle relaxants.

Drug interaction studies have not been conducted. No clinically significant cases of drug interaction have been reported.

The aesthetic effect of Botox^® usually becomes apparent within one week after the procedure and lasts for up to 4 months.

I confirm that my attending physician:

• informed me about the specific features of the procedure so that I could make a considered decision;
• gave me the opportunity to ask any questions of interest before the procedure and to receive comprehensive information;
• provided me with time to discuss the procedure protocol;
• obtained from me the most complete information possible about my health condition.

Therefore, I give my consent for this procedure to be performed by my attending physician.

I consent to photo and video recording of the procedure and authorize the physician to use my photo and video materials before and after the procedure for scientific purposes.

Batch number of Botox^®:____________

Date of the procedure:______________

Notes:_________________________

Patient’s surname, first name, patronymic/middle name:_______

Patient’s signature:_____“__” ___ 20__

Physician’s surname, first name, patronymic/middle name:_____

Physician’s signature:____“__” ___ 20__