Neuromodulator (Botox/Dysport®) Consent

I understand that I will be injected with a Neuromodulator in the area discussed with my provider.

Injection of a Neuromodulator into selected muscles will cause those specific muscles to halt their function (be paralyzed), thereby improving the appearance of wrinkles that these muscles have caused. I understand the goal is to decrease the wrinkles in the treated area. This paralysis is temporary, and re-injection is necessary within 3-4 months. It has been explained to me that other temporary and more permanent treatments are available. The possible side effects of a neuromodulator include but are not limited to:

  • Risks: I understand there is a risk of swelling, rash, headache, local numbness, pain at the injection site, bruising, respiratory problems, and allergic reaction.
  • Infection: Infections can occur which in most cases are easily treatable but in rare cases a permanent scarring in the area can occur
  • Most people have lightly, swollen, pinkish bumps where the injections were completed for a couple minutes to hours.
  • Although many people with chronic headaches or migraines often get relief from a treatment with a neuromodulator, a small percentage of patients get headaches following a treatment for the first day. In a very small percentage of patient these headaches can persist for several days or weeks.
  • Local numbness, rash, pain at injection site, flu like symptoms with mild fever, back pain.
  • Bruising is possible anytime you inject a needle into the skin. This bruising can last for several hours, days, weeks and in worst cases months.
  • Treatments: I understand more than one injection may be needed to achieve a satisfactory results.
  • I will follow all aftercare instructions as it is crucial I do so for healing.

As using a Neuromodulator (Botox/Dysport®) is not an exact science, there might be an uneven appearance of the face with some muscles more affected than others. In most cases this uneven appearance can be corrected by injecting a few extra units into the same or nearby muscles. However in some cases this uneven appearance can persist for several weeks to months. This is why it is so important to follow proper post-care.

This list is not meant to be inclusive of all possible risks associated with Botox/Dysport® as there are both known and unknown side effects associated with any medication or procedure.


The number of units injected is an estimate of the amount of Botox/Dysport® required to paralyze the muscles. I understand there is no guarantee of results of any treatment. I understand the regular charge applies to all subsequent treatments. No refunds will be given for treatments received.

I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I further agree in the event of non-payment, to bear the cost of collection, and/or court cost and reasonable legal fees should this be required.

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