CLIENT CONSENT FOR DYSPORT COSMETIC
Rationale
I am aware that when a small amount of DYSPORT is injected into a muscle it causes
weakness of that muscle. This appears in 3-4 days with full effect in 14 days and usually lasts
four months but can be shorter or longer. Mid, lower face and neck areas are off labels for use
of DYSPORT. For example: Frown lines between the eyebrows are due to contraction of a small
muscle, corrugated beneath the inner part of each eyebrow. Injecting Dysport into this muscle
will relax it causing improvement or disappearance of the frown lines.
Results and Postoperative Care
Risk and Complications
DYSPORT treatment of frown lines can cause minor temporary droop of one eyelid in approximately 2% of injections. This usually last 2-3 weeks. Occasional numbness of the forehead lasting 2-3 weeks, bruising and transient headache have occurred. In a very small number of individuals, the injection does not work as satisfactorily or for as long as usual.
Photographs
I authorize the taking of clinical photographs, I understand my identity will be protected.
Payment and Cancellation Policy
Payment is my responsibility and is due in full at the time of service. I understand that I will incur a fee of $100 for cancellation of any scheduled appointment without 24 hours notice.
Pregnancy and Neurologic Disease
I am not aware that I am pregnant or nursing nor that I have any significant neurologic disease.
I understand I will have the DYSPORT injected by Daniela Bobsin, RN. I have read the above and understand it. My questions have been answered satisfactorily by the Health Care Provider. I accept the risks and complications of the procedure.