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CONSENT FORM for Prophylaxis of Headaches in Adults
with Chronic Migraine

I am aware that when a small amount of purified botulinum toxin (Botox) is injected into a muscle it causes weakness in that muscle. The results start to appear in 3-4 days (full results in 3-4 weeks) and usually last 3 months. I must stay in an erect posture and I must not touch or manually manipulate the injection site with my fingers for a three hours post-injection period.

Risk and Complications
I understand that Botox treatment can cause temporary muscular weakness, musculoskeletal stiffness, neck pain or eyelid ptosis.
I authorize the taking of clinical photographs and their use for my personal treatment I understand my identity will be protected.
I am NOT pregnant


I have read the above and understand it My questions have been answered satisfactorily by the doctor or the nurse. I accept the risks and complications of the procedure.

Previous BOTOX® injections as a Chronic Migraine patient
Is the patient receiving BOTOX® for any other medical condition
Does the patient have any allergies?
Is the patient taking any other medications?
Thanks for submitting!
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