Botox Consent Form

  • I,
  • authorize Fusion Medical Aesthetics to perform neuromuscular relaxation injection(s).
  • Risks: This authorization is given with the understanding that any operation or procedure involves some risks and hazards; possible risks include ptosis (temporary drooping of eyelids), drooping of eyebrows, diplopia (double vision), swelling of the eyelids, blurred vision, decreased eyesight, dry eyes, twitch, bruising, pain, dry mouth, discomfort or pain in the injection site, tiredness, neck pain, allergic reaction, no effect, asymmetry, headache, and activation of shingles. Other unknown risks are also possible and could be fatal.
  • I have no history of neuromuscular disease(s), no allergy to eggs or cow’s milk, and am not currently pregnant or breastfeeding. I understand this is a cosmetic procedure, which has been FDA approved for the treatment of frown lines, crow’s feet and forehead lines only, though it has been used in other areas routinely. The drug, its effect, and expected outcomes have been discussed in detail with me by Dr. Lisa Gardner. I understand the information and request to proceed with this treatment.
  • I agree to not seek Botox treatment if I am pregnant or breastfeeding; this applies to the first treatment and all subsequent treatments (females only).
  • Results not guaranteed: I understand that no guarantee or assurance has been made as to the results of the procedure and that it may not cure the condition. The effects of the medicine are temporary, usually lasting 3-6 months, but this time period could be shorter or longer.
  • Patient’s consent: I have read and fully understand this consent form, and understand that I should not sign this form if all items, including all my questions, have not been explained or answered to my satisfaction or if I do not understand any of the terms or words contained in this consent form. I have no further questions.
  • By signing this form I acknowledge that I understand the procedure/consultation today is considered a cosmetic visit, is not covered under my insurance plan and therefore will not be submitted to my insurance company. I understand that I am responsible for this visit, and fully accept the fact that the charges incurred are out of pocket expenses. I, therefore, agree to pay, in full, the cost of this procedure/consultation.
  • If you have any questions as to the risks or hazards of the proposed procedures or any questions concerning them, ask your physician before signing this form. Do not sign unless you have read and thoroughly understand this form.
  • MM slash DD slash YYYY
    I consent to the taking of photographs by Dr. Lisa Gardner or her designee of me or parts of my body in connection with the aesthetic procedure(s) to be performed.

    I provide this authorization as a voluntary contribution in the interests of public education. I understand that such photographs shall become the property of Fusion Medical Aesthetics and may be retained by Fusion Medical Aesthetics or released by Fusion Medical Aesthetics for the limited purpose of including them in any print, visual or electronic media, specifically including, but not limited to, medical journals and textbooks, for the purpose of informing the medical profession or the general public about aesthetic procedures and methods.

    Neither I, nor any member of my family, will be identified by name in any publication. I understand that in some circumstances the photographs may portray features that will make my identity recognizable.

    I understand that I may refuse to authorize the release of any health information and that my refusal to consent to the release of health information will prevent the disclosure of such information, but will not affect the health care services I presently receive, or will receive, from Fusion Medical Aesthetics.

    I understand that I have the right to inspect and copy the information that I have authorized to be disclosed. I further understand that I have the right to revoke this authorization in writing at any time, but if I do so it won’t have any affect on any actions taken prior to my revocation. If I do not revoke this authorization, it will expire ten years from the date written below.

    I understand that the information disclosed, or some portion thereof, may be protected by state law and/or the federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). I further understand that, because Fusion Medical Aesthetics is not receiving the information in the capacity of a health care provider or health plan covered by HIPAA, the information described above may no longer be protected by HIPAA.

    I release and discharge Dr. Lisa Gardner, Fusion Medical Aesthetics, and all parties acting under their license and authority from all rights that I may have in the photographs and from any claim that I may have relating to such use in publication, including any claim for payment in connection with distribution or publication of the photographs.

    I certify that I have read the above Authorization and Release and fully understand its terms.