Botox and Dysport Consent

Patient Name(Required)

General Information

Botox® (Botulinum A toxin) is a purified protein that has been approved by the FDA since 1989 as a safe and effective treatment for eyelid spasms, muscle spasms causing crossed eyes, as well as facial spasms. It has also been shown to be an effective non-surgical treatment for facial lines and wrinkles. As we age, we develop wrinkles and creases on the face, partly due to the action of certain facial muscles on our skin. These muscles produce creases by the constant pull they exert on our skin. Injections of Botox into these specific muscles cause a temporary paralysis, which weakens the muscle, allowing skin to relax, and eliminating the wrinkle. Botox should be injected at no less than 3-month intervals to prevent the development of resistance to its action.
I understand that DR. KIMBERLY ROMAN, ON BEHALF OF ANEW, BODY, BEAUTY & WELLNESS SPA will inject Botox (Botulinum A Toxin) into the muscles in various areas to paralyze the muscles temporarily. Possible areas of injection are between the eyebrows (glabella), forehead, around the eyes (per-orbicular, crow’s feet), neck, lower face, lips, underarms, hands, or feet. By signing this consent form, I acknowledge that I understand the following facts about Botox injections: Botox corrects only wrinkles induced by facial muscle contractions. Skin wrinkles (not muscle related) require other forms of treatment, such as peels, Restylane® or collagen injections. I understand the goal is to decrease the wrinkles in the treated areas. I understand that complications are rare, but may include paralysis of other nearby muscles, temporary ptosis (drooping of eyelids), double vision, headache, local numbness, rash and bruising. Imbalance results are rare, and corrective injections can be made to restore the balance. I understand that other temporary and more permanent treatments are available including soft tissue augmentation, fat or other fillers, surgical excision of the muscles, and brow lifts. There is no guarantee that the results will be satisfactory to me, but the provider will use their best efforts and judgment on my behalf. The effects will start to appear in 3 days and maximum results will be apparent approximately 10 days after injections. I understand that the FDA has approved Botox injections for other problems concerning the eye and face, as well as muscle induced wrinkles and excessive sweating.

Medication Policy

ANEW, BODY, BEAUTY AND WELLNESS SPA requires all medicated patients to be picked up by a family member, friend, or a trusted form of transportation after treatment. ANEW, BODY, BEAUTY AND WELLNESS SPA is in no way liable or held responsible after the patient leaves the center. I understand that there can be no exception to the above policy and will comply as requested.
Check Here if Medication Policy is Not Applicable


I authorize ANEW, BODY, BEAUTY AND WELLNESS SPA and/or their representative(s), to take photographs of me for the following procedure(s) and for the medical purposes to be used for my care and in my medical chart. I have read the above information and understand the procedure, risks, and potential complications. My questions have been answered satisfactorily. I accept the risks and complications of the procedure and elect to proceed with one or more neurotoxin treatments performed at ANEW, BODY, BEAUTY AND WELLNESS SPA.
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