Dr. Reece offers BOTOX® for the relief of wrinkles. Below is the consent form used. It will probably address most of the common questions the patient asks about the procedure.
To the Patient: Cosmetic procedures, including collagen, BOTOX® Cosmetic, Restylane are individualized processes not discrete procedures. This means that each patient undergoing these treatments may need enhancements to have optimal results. Please give us your opinions following your procedure so that we may provide you with the best result possible. Also, when an enhancement is performed, you will be charged for any additional materials used (this material could have been used at the first visit in a less gradual approach.)
You have the right to be informed about your skin condition and treatment so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to better inform you so that you may give or withhold your consent for the treatment program. I have requested that Dr. Ronald Reece attempt to improve my facial expression lines with Botox. This is the trademark for botulinum toxin. BOTOX® has been used for more than a decade in children and adults to improve muscle spasms of the facial muscles. The toxin is a purified protein. BOTOX® injections weaken muscles, thereby relaxing frown lines, crow's feet and other expression lines.
Although the results are usually dramatic, I have been informed the practice of medicine is not an exact science and that no guarantees can be or have been made concerning expected results in my case. I understand that there are alternatives to this treatment and that not having any treatment are options for me Initial if true____
BOTOX® is a cumulative treatment and your treatments will have better effects after several treatments than after a single treatment.
Initial if true____
Bruising may occur after BOTOX® injections. Substances that increase bruising include Vitamin E, aspirin, motrin and other non-steroidal anti inflammatory.
Initial if true____
The solution is injected with a small needle into the muscle. You see the benefits develop over the next five to seven days. Less frowning will be possible.
Initial if true____.
Side effects and complications are unusual but possible. Occasionally, slight swelling, and/or bruising may last for several days after the injections. Rarely, an adjacent muscle may be weakened for several weeks after an injection. This may cause difficulty in raising my eyelid or double vision. Headaches and flu-like symptoms may also occur following BOTOX® injections. Less likely but possible complications include infection, nerve damage, skin necrosis (dead skin which may leave scars and/or necessitate skin grafting and anaphylaxis (allergic reaction) including death. I have been advised of the risks involved is such treatment, the expected benefits of such treatment, and alternative treatments including no treatment at all.
Initial if true____
I understand that several sessions may be needed to complete the injection series and the multiple sessions are planned I understand that there is a separate charge for any subsequent treatments.
Initial if true_____
I agree that this constitutes full disclosure, and that is supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs, and that I have had sufficient opportunity for discussion and to ask questions.
Initial if true__________
I understand that I need to remain upright and not exercise for 24 hours following my treatment.___
Initial if true____
I give Dr. Ronald Reece permission to use photographs of me for education and/or publicity. I will contact you again if photographs will be used for publicity.
Initial if true____
Ronald E. Reece M.D.
Dermatologist-Board Certified
2701 Old Eureka Way Suite 2A
Redding, CA 96001
530-246-0236
BOTOX®™ Post-Operative Instructions
1. Do not lie down for 4 hours.
2. You may apply an ice pack to the area for 15-20 minutes several times during the first 12 hours. This may reduce swelling and bruising. (An ice pack can be made by filling a small Zip Lock baggy with ice and surrounding it with a wash cloth.)
3. Work the treated areas by wrinkling the forehead or frowning for 1 - 2 hours.
4. Do not exercise (running, aerobics, weight lifting, etc…) for 24 hours.
5. No aspirin or ibuprofen for 24 hours.
6. It will take 3 - 7 days for the full effect to be achieved.
If you have any questions or concerns, we are here for you,
please call 530-246-0236.
BOTOX® is a regestered trrademark of Allergan, INC.