Disclosure to Patient

Being fully informed about your condition and treatment will help you decide whether or not to undergo BOTOX® Cosmetic treatment. This disclosure is not meant to alarm you; it is provided to help you make an informed decision and give your consent.

⸻

Procedure Overview

I have requested that Dr. Panzer and/or Meagan Sullivan, NP attempt to improve my facial lines with BOTOX® Cosmetic (Botulinum Toxin Type A).

* BOTOX® Cosmetic is manufactured by Allergan Inc.
* It has been used for many years to treat muscle-related conditions and cosmetic concerns
* It works by relaxing overactive muscles, improving the appearance of wrinkles such as vertical lines between the eyebrows
* Effects typically begin within 2–7 days after treatment

Use in other facial areas may be considered but is not always FDA-approved.

⸻

Expected Results

* Reduction in the appearance of wrinkles and facial lines
* Results are often noticeable within a few days
* Results are temporary, and repeat treatments are required

Note: The practice of medicine is not an exact science, and no guarantees have been made regarding results.

⸻

Risks and Side Effects

The most common side effects include:

* Headache
* Respiratory infection
* Flu-like symptoms
* Temporary eyelid droop
* Nausea
* Bruising at injection sites

Additional considerations:

* BOTOX® should not be used if there is an active infection at the injection site
* Mild bruising may occur

I have been advised of the risks, expected benefits, and alternative treatments, including no treatment.

⸻

Acknowledgments

* I understand that results are temporary and multiple sessions may be needed
* I acknowledge that I have had the opportunity to ask questions
* All of my questions have been answered to my satisfaction

⸻

Consent

I agree that this constitutes full disclosure and supersedes any previous verbal or written disclosures.

I certify that I have read and fully understand the above information and have had sufficient opportunity to discuss the treatment.

I consent to BOTOX® Cosmetic treatment today and for future treatments as needed.