Form & Consent

Botulinum Toxin Injection

Personal Information

Last Name

First name

Date of birth

Phone number

Address

Zip Code

City

Center

How did you hear about the center?

Occupation

Sex

Form and Consent

IMPORTANT INFORMATION

• INDICATIONS

The treatment involves injecting very small doses of purified botulinum toxin directly into the muscles responsible for so-called “expression lines.” This reduces their ability to contract, resulting in a natural smoothing of the wrinkles. The result is a relaxed forehead that rejuvenates the face and softens the eyes.

• RESULT

The effects become apparent as early as the first week, peak between two weeks and one month, and last for approximately 4 to 6 months. The return to the original state is gradual, and muscle contractions slowly resume starting around the 4th or 6th month. A minimum interval of 3 months must be observed between each session.

• TECHNICAL

The injections are administered at specific points using tailored doses, depending on the location and severity of the wrinkles. No anesthesia is required, and the injections are rarely painful.

• SIDE EFFECTS

Temporary bruising at the injection sites, mild swelling of the eyelids for 24 to 48 hours, as well as a temporary sensation of tightness in the forehead and eyelid area. Ptosis of the upper eyelid, manifested by limited eyelid opening. This effect is rare and is always reversible; its duration is shorter than that of botulinum toxin’s effect on wrinkles and may last up to approximately 4 weeks. Your doctor may prescribe local treatment if necessary. Headaches may occur in the first few days following the injection.

• INFORMATION ON POTENTIAL RISKS

Infectious reactions, bruising, hardening, or lumps may appear at the injection site.

• PRECAUTIONS BEFORE INJECTION

If you are currently taking anticoagulants or antiplatelet agents (such as aspirin), special precautions must be taken. You must inform your healthcare provider of any medications you are taking. • Information on potential risks Infections, bruising, hardening, or lumps may develop at the injection site.

• POST-INJECTION PRECAUTIONS

Avoid lying down for four hours after the procedure, tilting your head downward or completely backward, or massaging the injection sites. Do not use a sauna.

• CONTRAINDICATIONS

– Absolute contraindications include myasthenia gravis, certain neuromuscular disorders, concurrent treatment with aminoglycosides, and allergy to botulinum toxin. – Active inflammation or infection at the injection sites (acne, herpes, etc.) – Pregnancy and breastfeeding

I certify that the doctor has explained to me all the known risks associated with this procedure.

I acknowledge that I was able to ask him any questions regarding this procedure and that the explanations were clear and comprehensive, and that I have informed this doctor of my medical history, as well as the procedures, care, and treatments I have received and have undergone to date,

I give my free and informed consent to the procedure described above, with full full knowledge of the facts.

The form has been successfully submitted.

An error occurred.