{"id":32343,"date":"2025-01-29T18:15:17","date_gmt":"2025-01-29T15:15:17","guid":{"rendered":"https:\/\/estportal.com\/informirovannoe-soglasie-na-vvedenie-preparata-botoks\/"},"modified":"2026-06-06T01:01:36","modified_gmt":"2026-06-05T22:01:36","slug":"informed-consent-botox","status":"publish","type":"post","link":"https:\/\/estportal.com\/en\/informed-consent-botox\/","title":{"rendered":"Informed Consent for Botox Administration"},"content":{"rendered":"<h2 style=\"text-align: center;\">Informed Consent for Botox<sup>\u00ae<\/sup> Administration<\/h2>\n<p style=\"text-align: justify;\">I, <em>(patient\u2019s surname, first name, patronymic\/middle name)<\/em><\/p><!--ADSENSE BOOSTER & MNANAGMENT PLUGIN BY InfoTheme (www.infotheme.in)--><div id='advertisment_abm' style='text-align:Ad Alignment;'><div id='Inner_ads'><script async src=\"\/\/pagead2.googlesyndication.com\/pagead\/js\/adsbygoogle.js\"><\/script>\r\n<!-- 1 -->\r\n<ins class=\"adsbygoogle\"\r\n     style=\"display:block\"\r\n     data-ad-client=\"ca-pub-7825012234752165\"\r\n     data-ad-slot=\"8322009399\"\r\n     data-ad-format=\"auto\"><\/ins>\r\n<script>\r\n(adsbygoogle = window.adsbygoogle || []).push({});\r\n<\/script><\/div><\/div><\/p>\n<p style=\"text-align: justify;\">born on________________________,<\/p>\n<p style=\"text-align: justify;\">residing at:______________________,<\/p>\n<p style=\"text-align: justify;\">contact phone number:______________<\/p>\n<p style=\"text-align: justify;\">give my consent to undergo the procedure of Botox<sup>\u00ae<\/sup> administration for cosmetic purposes,<\/p>\n<p style=\"text-align: justify;\">performed by the physician <em>(physician\u2019s surname, first name, patronymic\/middle name)<\/em><\/p>\n<p style=\"text-align: justify;\">Physician\u2019s contact phone number:______<\/p>\n<h3 style=\"text-align: justify;\"><strong>I confirm that I have been informed about the course of the procedure and the product to be used.<\/strong><\/h3>\n<p style=\"text-align: justify;\"><a href=\"https:\/\/estportal.com\/en\/botulinum-toxin-cosmetology-poison-or-medicine\/\" target=\"_blank\" rel=\"noopener\">Botox<sup>\u00ae<\/sup><\/a> is intended for the correction of facial expression lines and is administered by intramuscular injection.<\/p>\n<p style=\"text-align: justify;\">Botox<sup>\u00ae<\/sup> 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.<\/p>\n<p style=\"text-align: justify;\">The use of <a href=\"https:\/\/estportal.com\/en\/botulinum-toxin\/\" target=\"_blank\" rel=\"noopener\">Botox<sup>\u00ae<\/sup><\/a> for the correction of vertical glabellar lines is not recommended in patients under 18\u00a0years of age or over 65\u00a0years of age.<\/p>\n<h3 style=\"text-align: left;\"><strong>Contraindications<\/strong><\/h3>\n<p style=\"text-align: justify;\"><strong>I have been informed of the list of contraindications to the administration of Botox<sup>\u00ae<\/sup>.<\/strong><\/p>\n<p style=\"text-align: justify;\"><span style=\"text-decoration: underline;\">General contraindications<\/span>:<\/p>\n<ul style=\"text-align: justify;\">\n<li>confirmed hypersensitivity to any component of the product;<\/li>\n<li>inflammation at the intended injection site or sites;<\/li>\n<li>acute phase of infectious diseases;<\/li>\n<li>pregnancy and lactation.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\"><span style=\"text-decoration: underline;\">For the treatment of blepharospasm and correction of facial muscle activity<\/span>:<\/p>\n<ul style=\"text-align: justify;\">\n<li>pronounced gravitational ptosis of the facial soft tissues;<\/li>\n<li>pronounced herniation in the upper and lower eyelid area.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\"><span style=\"text-decoration: underline;\">Botox<sup>\u00ae<\/sup> should be used with caution in the following cases<\/span>:<\/p>\n<ul>\n<li style=\"text-align: justify;\">in cases of pronounced facial asymmetry;<\/li>\n<li style=\"text-align: justify;\">in cases of ptosis, dermatochalasis, or deep scars;<\/li>\n<li style=\"text-align: justify;\">in patients with thick, dense skin or when vertical glabellar lines do not show significant smoothing during mechanical stretching of the skin.<\/li>\n<\/ul>\n<h3 style=\"text-align: left;\"><strong>Adverse Reactions<\/strong><\/h3>\n<p style=\"text-align: justify;\"><strong>I have been informed of the list of adverse reactions that may occur when Botox<sup>\u00ae<\/sup> is used for the correction of facial expression lines.<\/strong><\/p>\n<p style=\"text-align: justify;\"><span style=\"text-decoration: underline;\">Adverse reactions associated with the correction of facial expression lines<\/span>:<\/p>\n<ul style=\"text-align: justify;\">\n<li>nervous system disorders: headache, paresthesia;<\/li>\n<li>eye disorders: ptosis;<\/li>\n<li>gastrointestinal disorders: nausea;<\/li>\n<li>skin disorders: erythema, a sensation of skin tightness;<\/li>\n<li>musculoskeletal system disorders: muscle weakness;<\/li>\n<li>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.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">The frequency of adverse reactions is 1\u201310%.<\/p>\n<p style=\"text-align: justify;\"><strong>I have been warned<\/strong> that if any side effect becomes more pronounced, or if a side effect not listed here occurs, I should immediately contact my attending physician.<\/p>\n<h3 style=\"text-align: left;\"><strong>Interaction with Other Medicinal Products<\/strong><\/h3>\n<p style=\"text-align: justify;\">When used concomitantly, the effect of Botox<sup>\u00ae<\/sup> may be potentiated by aminoglycoside antibiotics, erythromycin, tetracycline, polymyxins, and agents that reduce neuromuscular transmission, especially curare-like muscle relaxants.<\/p>\n<p style=\"text-align: justify;\">Drug interaction studies have not been conducted. No clinically significant cases of drug interaction have been reported.<\/p>\n<p style=\"text-align: justify;\">The aesthetic effect of Botox<sup>\u00ae<\/sup> usually becomes apparent within one week after the procedure and lasts for up to 4\u00a0months.<\/p>\n<p style=\"text-align: justify;\"><strong>I confirm that my attending physician:<\/strong><\/p>\n<ul style=\"text-align: justify;\">\n<li>informed me about the specific features of the procedure so that I could make a considered decision;<\/li>\n<li>gave me the opportunity to ask any questions of interest before the procedure and to receive comprehensive information;<\/li>\n<li>provided me with time to discuss the procedure protocol;<\/li>\n<li>obtained from me the most complete information possible about my health condition.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\"><strong>Therefore, I give my consent for this procedure to be performed by my attending physician.<\/strong><\/p>\n<p style=\"text-align: justify;\"><em>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.<\/em><\/p>\n<p><a href=\"https:\/\/estportal.com\/wp-content\/uploads\/2019\/01\/EstPortal-21.jpg\" target=\"_blank\" rel=\"noopener\"><img decoding=\"async\" class=\"aligncenter wp-image-67889 size-full\" src=\"https:\/\/estportal.com\/wp-content\/uploads\/2019\/01\/EstPortal-21.jpg\" alt=\"\u0418\u0437\u043e\u0431\u0440\u0430\u0436\u0435\u043d\u0438\u0435 \u043a \u0442\u0435\u043c\u0435: \u0418\u043d\u0444\u043e\u0440\u043c\u0438\u0440\u043e\u0432\u0430\u043d\u043d\u043e\u0435 \u0441\u043e\u0433\u043b\u0430\u0441\u0438\u0435 \u043d\u0430 \u0432\u0432\u0435\u0434\u0435\u043d\u0438\u0435 \u043f\u0440\u0435\u043f\u0430\u0440\u0430\u0442\u0430 \u0411\u043e\u0442\u043e\u043a\u0441\" width=\"1000\" height=\"1217\" srcset=\"https:\/\/estportal.com\/wp-content\/uploads\/2019\/01\/EstPortal-21.jpg?v=1780689809 1000w, https:\/\/estportal.com\/wp-content\/uploads\/2019\/01\/EstPortal-21-247x300.jpg?v=1780689809 247w, https:\/\/estportal.com\/wp-content\/uploads\/2019\/01\/EstPortal-21-841x1024.jpg?v=1780689809 841w, https:\/\/estportal.com\/wp-content\/uploads\/2019\/01\/EstPortal-21-768x935.jpg?v=1780689809 768w\" sizes=\"(max-width: 1000px) 100vw, 1000px\" \/><\/a><\/p>\n<p style=\"text-align: justify;\">Batch number of Botox<sup>\u00ae<\/sup>:____________<\/p>\n<p style=\"text-align: justify;\">Date of the procedure:______________<\/p>\n<p style=\"text-align: justify;\">Notes:_________________________<\/p>\n<p style=\"text-align: justify;\">Patient\u2019s surname, first name, patronymic\/middle name:_______<\/p>\n<p style=\"text-align: justify;\">Patient\u2019s signature:_____\u201c__\u201d ___ 20__<\/p>\n<p style=\"text-align: justify;\">Physician\u2019s surname, first name, patronymic\/middle name:_____<\/p>\n<p style=\"text-align: justify;\">Physician\u2019s signature:____\u201c__\u201d ___ 20__<\/p>\n<!--ADSENSE BOOSTER & MNANAGMENT PLUGIN BY InfoTheme (www.infotheme.in)--><div id='advertisment_abm' style='text-align:;'><div id='Inner_ads'><script async src=\"\/\/pagead2.googlesyndication.com\/pagead\/js\/adsbygoogle.js\"><\/script>\r\n<ins class=\"adsbygoogle\"\r\n     style=\"display:block\"\r\n     data-ad-format=\"autorelaxed\"\r\n     data-ad-client=\"ca-pub-7825012234752165\"\r\n     data-ad-slot=\"5062927836\"><\/ins>\r\n<script>\r\n     (adsbygoogle = window.adsbygoogle || []).push({});\r\n<\/script><\/div><\/div>","protected":false},"excerpt":{"rendered":"<p>Sample informed consent form for Botox administration.<\/p>\n","protected":false},"author":180,"featured_media":67890,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"footnotes":""},"categories":[867],"tags":[1012,1013],"class_list":["post-32343","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-injection-techniques","tag-botox","tag-botulinum-toxin"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v26.6 (Yoast SEO v26.6) - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Informed Consent for Botox Administration &#8226; ESTportal<\/title>\n<meta name=\"description\" content=\"Botox informed consent form covering indications, contraindications, potential side effects, drug interactions and essential patient 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