Doctor & Facility: The procedure will be performed by my treating physician, W. Blane Richardson, MD, at Southern Grace Pain & Regenerative Medicine.
To the patient: Being fully informed about your condition and treatment will help you make the decision whether or not to undergo Botulinum Toxin A injection therapy. This disclosure is not meant to alarm you; it is simply an effort to better inform you so that you may give or withhold your consent for this treatment
I have requested that Southern Grace Pain & Regenerative Medicine attempt to temporarily improve the look of moderate to severe frown lines between the eyebrows (glabellar lines). The results of Botulinum Toxin A injections are: decreased wrinkles, smoother skin, less pronounced frown lines, less noticeable frown lines, although the practice of medicine is not an exact science and no guarantees can be or have been made concerning expected results.
I attest that I am not pregnant, trying to become pregnant, or breastfeeding.
Alternative methods and their benefits and disadvantages have been explained to me.
Botulinum Toxin A is injected with a tiny needle into the muscle; you see the benefits develop over several days to approximately 3 weeks.
The most common side effects observed in the clinical trials include the following: headache; eyelid drooping, upper respiratory tract infection, and increased white blood cell count in your blood. Injections should not be performed if there is an infection at the injection site. Additionally, slight temporary bruising may occur at the injection site. As with all injections, there is a risk of infection at the injection site. I have been advised of the risks involved in such treatment, the expected benefits of such treatment, and alternative treatments, including no treatment at all.
I understand the results are temporary and several sessions may be needed for optimal results. The duration of effect varies for each individual and is dependent on [insert factors that may affect how long effect lasts for individual patients]. In 2 long-term safety studies, patients received an average of 3 treatments over the course of 1 year.1
I understand that this procedure is an “elective” procedure and that payment is my responsibility. Any expenses which may be incurred by medical care I elect to receive outside of this office, such as, but not limited to, dissatisfaction of my treatment outcome will be my sole financial responsibility. Payment in full for all treatments is required at the time of service and is non-refundable.
I consent to having before and after pictures taken for documentation purposes only. These will never be shared outside my chart without my explicit written consent.
I certify that I have read and fully understand the above information, the procedure has been fully explained by my treating physician and I authorize and consent to the performance of the procedure.
