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Toxin Botulinum Type A: Botox® Cosmetic & Dysport Consent Form

Botox® Cosmetic
Botox Cosmetic is indicated for the temporary improvement in the appearance of moderate to severe glabellar and lateral canthal lines associated with corrugator and or procerus muscle activity in adult patients < 65 years of age.

Botox® Cosmetic for injection is sterile vacuum-dried purified protein botulinum toxin type A. produced from the fermentation of Hall strain Clostridium botulinum type A grown in a medium containing casein hydrolysate. glucose. and yeast extract. intended for intramuscular use. Botox Cosmetic blocks neuromuscular transmission by binding. to acceptor sites on motor nerve terminals. entering the nerve terminals. and inhibiting the release of acetylcholine. When injected intramuscularly at therapeutic doses. Botox Cosmetic procedures partial chemical denervation of the muscle resulting in a localized reduction in muscle activity.

Administration of Botox® Cosmetic is not recommended during pregnancy and nursing.

Dysport TM
Dysport TM is an acetylcholine release inhibitor and a neuromuscular blocking agent indicated for the temporary improvement in the appearance of moderate to severe glabellar lines associated with procerus and corrugator muscle activity in adult patients

The effects of Dysport TM and all botuli
num toxin products may spread from the area of injection to produce symptoms consistent with the botulinum toxin effect. These symptoms have been reported hours to weeks after injection. Swallowing and breathing difficulties can be life-threatening and there have been reports of death. The risk of symptoms is probably greatest in children treated for spasticity but symptoms can also occur in adults, particularly in those patients who have underlying conditions that would predispose them to these symptoms.

ysport TM is contraindicated in patients with known hypersensitivity to any botulinum toxin preparation or to any of the components in the formulation. This product may contain trace amounts of cow's milk protein. Patients known to be allergic to cow's milk protein should not be treated with Dysport TM. Dysport TM is contraindicated for use in patients with infection at the proposed injection site(s).

Acknowledgment, Authorization and Release

I understand and accept that the most likely risk complications of Botox® Cosmetic and Dysport

injections, including but not limited to:

•    Paralysis of a nearby muscle that could interfere with the opening of the eye(s)
•    Local numbness
•    Headache, nausea, or flu-like symptoms
•    Swallowing, speech, or respiratory disorders
•    Swelling, bruising or redness at the injection site
•    Disorientation and double vision
•    Temporary asymmetrical appearance
•    Abnormal or lack of facial expression

•    Inability to smile when injected in the lower face
•    Facial Pain
•    Product ineffectiveness

Acknowledgment, Authorization and Release

•    Muscle atrophy
•    Nerve irritability
•    Production of antibodies with unknown effects on general health

Acknowledgment, Authorization
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