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Informed Consent Form for Neuromodulator Treatment

First name:

Last name:

Date of birth:

Phone / Cell phone:

Address:

The purpose of this informed consent form is to provide written information regarding the risks, benefits, and alternatives of the procedure described below. This document complements the discussion you have had with your physician or healthcare professional. It is important that you fully understand this information. If you have any questions regarding the procedure, please ask your physician or healthcare professional before signing this form.

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THE TREATMENT

Botulinum toxin (Botox® and similar products) is a neuromodulator produced by the bacterium Clostridium botulinum. It can relax the facial and neck muscles responsible for expression lines or certain types of facial pain.

The most commonly treated areas include:

 

  • Glabellar area (frown lines between the eyebrows)

  • Crow's feet (outer corners of the eyes)

  • Forehead lines

  • Perioral radial lines (smoker's lines)

  • Head and neck muscles

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The neuromodulator is diluted in a carefully controlled solution and injected using a very fine needle, making the procedure nearly painless. Patients may experience a mild burning sensation during the injection. The procedure takes approximately 15–20 minutes, and results may last up to 3 months. With repeated treatments, the duration of the effects may increase.

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RISKS AND COMPLICATIONS

Before undergoing this procedure, it is essential to understand the associated risks. No procedure is entirely risk-free. The following risks may occur, although unforeseen or unlisted risks may also exist. Some of these risks, if they occur, may require hospitalization or prolonged outpatient treatment.

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I understand that there are risks and side effects inherent to any invasive procedure. These include, but are not limited to:

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  1. Discomfort, swelling, redness, and bruising after treatment.

  2. Double vision.

  3. Weakness affecting the tear duct muscles.

  4. Post-treatment bacterial and/or fungal infection requiring additional treatment.

  5. Allergic reaction.

  6. Mild temporary drooping of one or both eyelids (approximately 2% of injections), usually lasting 2–3 weeks.

  7. Occasional forehead numbness lasting up to 2–3 weeks.

  8. Temporary headaches.

  9. Flu-like symptoms.

  10. Unsatisfactory or undesired results.

 

PREGNANCY, ALLERGIES, AND NEUROLOGICAL CONDITIONS

I certify that I am not pregnant, am not attempting to become pregnant, and am not breastfeeding. I do not have any significant neurological disease, including but not limited to myasthenia gravis, multiple sclerosis, Lambert-Eaton syndrome, amyotrophic lateral sclerosis (ALS), or Parkinson's disease. I have no known allergy to botulinum toxin or human albumin.

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ALTERNATIVE PROCEDURES

The alternatives to this procedure and the available treatment options have been fully explained to me.

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PAYMENT

I understand that this is an elective procedure and that payment is my responsibility and is due at the time of treatment.

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RIGHT TO DISCONTINUE TREATMENT

I understand that I have the right to discontinue treatment at any time.

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CLINICAL PHOTOGRAPHS

I authorize the taking of clinical photographs and videos for treatment documentation, follow-up, and/or consultation with other healthcare professionals when necessary.

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RESULTS

I understand that when small amounts of purified neuromodulator are injected into a muscle, they cause temporary weakening or paralysis of that muscle. Effects generally appear within 2 to 10 days and usually last up to 3 months, although they may be shorter or longer. In a small number of individuals, the treatment may not produce satisfactory results, may not last as long as expected, or may not be effective at all.

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I understand that I will not be able to use the treated muscles as before while the medication is active, but normal muscle function will gradually return after several months, at which time additional treatment may be appropriate. I also understand that I must remain upright and avoid manipulating the treated area(s) for two hours following the injections.

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I understand that this is an elective procedure, and I voluntarily consent to receive neuromodulator injections to treat dynamic facial wrinkles, temporomandibular joint (TMJ) disorders, bruxism, and certain types of orofacial pain, including headaches and migraines. The procedure has been fully explained to me. I also understand that all treatment is solely between myself and the physician or healthcare professional providing my care, and that any post-treatment questions or concerns should be directed to them.

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I have read and understood the information above. My questions have been answered to my satisfaction. I accept the risks and possible complications associated with this procedure and understand that no specific results can be guaranteed. I also certify that if my medical history changes, I will immediately inform the physician or healthcare professional who is treating me. I declare that I am able to read and write in English.

I consent to and authorize neuromodulator dental/medical treatment.

Signature du dentiste

Date

Je suis le dentiste qui a discuté des risques, bénéfices et alternatives ci-dessus avec le patient. Le patient a eu l’opportunité de poser toutes ses questions et s’est vu offrir une copie de ce consentement éclairé. Le patient a été informé de contacter mon cabinet en cas de questions ou préoccupations après cette procédure. 

Signature du dentiste

Date

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