Loading...

Patient Consent Form

BOTOX® Cosmetic

Date of Treatment: May 9, 2025

Being fully informed about your condition and treatment will help you make the decision whether or not to undergo BOTOX® Cosmetic treatment. 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 fo this treatment. 

I have requested that Restorative Skincare under the supervision of Dr. Adora Poon (Medical Director), attempt to improve my facial lines and enhance facial shaping with BOTOX® Cosmetic. This is the Allergan, Inc. trademark for Botulinum Toxin Type A. These injections have been used for nearly two decades to improve spasms of the muscles around the eye, to correct double vision due to muscle imbalance as well as numerous other neurological uses. BOTOX® Cosmetic is approved by the FDA to improve the appearance of the vertical lines between the eyebrows. Injections in other areas to improve appearance of facial lines and for facial shaping have been well documented in the literature, although are considered “off label” uses. The results of BOTOX® Cosmetic area usually dramatic, although the practice of medicine is not an exact science and no guarantees can be or have been made concerning expected results.


BOTOX® Cosmetic solution is infected with a tiny needle into the skin and muscle. You should see the benefits develop over the next seven days to two weeks, although complete evaluation of the outcome from treatment is evaluated at two weeks. A decreased appearance of frowning or creasing of other lines and/or a change in specific facial grimacing will be the result of this treatment.


The most common side effects are headache, respiratory infection, flu syndrome, temporary eyelid droop and nausea. BOTOX® Cosmetic should not be used if there is an infection at the injection site. Additionally, slight temporary bruising may occur 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 that the results are temporary and repeat treatments are needed to maintain the desired results every 3-4 months.


I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have sufficient opportunity for discussion and to ask questions. I consent to this BOTOX® Cosmetic treatment today and for all subsequent treatments. 

BOTOX® COSMETIC PRE AND POST CARE INSTRUCTIONS

  1. Restorative Skincare only uses FDA approved Allergan manufactured BOTOX® Cosmetics.
  2. It is helpful to avoid blood thinning over-the-counter medications such as Aspirin, Motrin and Aleve. Tylenol is OK to use. Please notify practitioner if you are using prescription or non-prescription blood thinners so extra precaution can be taken to avoid bruising. If bruising occurs, it is most common around the eyes and can be covered using a green or yellow cover-up stick. While we make very effort to avoid bruising, this may occur because the skin around the eyes is very thin and there are several small vessels in this area. Bruising is usually minimal and may take up to 7 days to resolve completely.
  3. If this is your first time receiving BOTOX® treatment at our office, a “Before” photo may be taken. Your treatment will take effect anywhere from 2 days to 2 weeks, but most commonly within 3-5 days. Since everybody is different, your BOTOX® Cosmetic treatment is tailored specifically for you and therefore we would like to see you back in 2 weeks for a quick check of your treatment outcome. Any refinements to your dose will be done at that time at $12 per unit.
  4. We would like to see you return in 2 weeks to make sure both you and your practitioner are satisfied with the results. We appreciate your trust in us. At that time we may also take your “After” photo for your patient file. This photo will not be shared without your expressed written permission.
  5. Immediately following your treatment, please DO NOT lie down for 2 hours.
  6. Avoid any massage or pressure to the area, as this may disrupt placement of the drug. If you would like to re-apply makeup, please do so gently over the treated area.
  7. Refrain from heavy exercise for 24 hours.
  8. Contract and release the treated muscles every few minutes over the next hour. This helps with the “uptake” of the drug.
  9. Allergan, the manufacturer of BOTOX®, as well as our own patient experiences, report the average duration of results is approximately 3-4 months. It is important to maintain regular injection intervals to maintain an optimal aesthetic result and prevent returning to your original pre-treatment condition.
  10. Let us know if you have any comments, questions or concerns. We are committed to patient education, safety and care.

By signing above, I acknowledge I have read and understand this document.

Date of Signature: May 9, 2025 

First Participant's Name

First Name*

Middle Name

Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!