Summit Medical Group
Plastic Surgery Center
Patient Label
________________________________________________________________________
Consent for Botox Treatment
Botox is approved by the FDA for treatment of skin wrinkles in the forehead and crow’s
feet (laugh lines around the eyes). The effect starts in 1-2 days and typically lasts 3-4
months. Botox should not be given to pregnant women or nursing mothers. Minor
bruising, redness, and pain at the injection site is common with Botox treatments. Less
common problems can happen, such as headaches, droopy eyelids, or temporary
asymmetry. Severe allergies are very rare, and occasionally there may be incomplete
resolution of the wrinkles. Ideally, patients should avoid blood thinning medications
before Botox treatment. If a patient likes the effect, additional treatments are usually
given in 3-4 months.
By signing below, you acknowledge that you have had read and understand the above
statement, and authorize the physician to perform treatment with Botox in such areas that
have been discussed during your visit.
Patient Signature ________________________________________ Date __/___/___
Consent for Cosmetic Filler Treatment
Cosmetic fillers are used to treat signs of aging, such as facial lines, hollow areas,
wrinkles, and other areas that would cosmetically benefit from a fuller and more youthful
appearance. With most fillers, the effect is usually seen soon after the treatment. There
may be some short term swelling, bruising, and lumpiness. Redness and mild discomfort
at the injection site can happen, but usually disappears quickly. Allergies to fillers are
not common, and testing is only done prior to injection if necessary. If the treated lines
are very deep or very set-in, the smoothing effect may be less complete than desired.
Depending on the specific product used, the effects disappear anywhere from 2 months to
2 years. The following product(s) will be used during this visit:
 Collagen
 Juvederm
 Restylane
 Radiesse
 Sculptra
By signing below, you acknowledge that you have had read and understand the above
statement, and authorize the physician to perform treatment with the fillers indicated
above in such areas that have been discussed during your visit.
Patient Signature ________________________________________ Date __/___/___