|
History
|
|
|
Do you have
|
|
|
Hypersensitivity to Botulinum A toxin products
|
|
|
Infection at the proposed injection site(s)
|
Bleeding Disorders
|
|
Cardiac Disease
|
Active Skin Disease
|
|
Do you or a family member have
|
|
|
Amyotropic Lateral Sclerosis
|
Motor Neuropathy
|
|
Myasthenia Gravis
|
Lambert-Eaton Syndrome
|
|
Facial Nerve Palsy
|
|
|
Are you
|
|
|
Pregnant
|
Breast-feeding
|
|
Medications
|
|
|
Do you take or have recently been on any of the following medications
|
|
|
Warfarin or Anti-Platelet Agents
|
Quinidin
|
|
Aminoglycosides
|
Magnesium Sulfate
|
|
Curare-like Nondepolarizing Blockers
|
Anticholinesterases
|
|
Lincosamides
|
Succinylcholine Chloride
|
|
Polymyxins
|
|
|
Physical
|
|
|
Glabellar lines smoothed out by physically spreading them apart
|
|
|
Skin infection at site of injection
|
Evidence of muscular atrophy
|
|
Evidence of petechia or bruising
|
Facial Asymmetry
|
|
Ptosis
|
Deep dermal scarring
|
|
Thick sebaceous skin
|
Dermatochalasis (excessive redundant skin)
|
|
NP/PA
|
Date
|
|
CONSENT TO BOTULINUM TOXIN “A” TREATMENT
|
|
|
RISKS AND COMPLICATIONS
|
PHOTOGRAPHS
|
|
PREGNANCY, ALLERGIES & NEUROLOGIC DISEASE
|
|
|
PAYMENT
|
RESULTS
|
|
Signature
|
|
|
TREATMENTS
|
|
|
Signature
|
|
