Rationale
I am aware that when a small amount of DYSPORT is injected into a
muscle it causesweakness 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 Post-treatment Care
1. I understand that I will not be able to move the treated muscle/s while the
injection iseffective but that this will reverse itself after a period of months at
which time re-treatment is appropriate.
2. I understand that I must stay in the erect posture and that I must not
manipulate the area of the injection site for the four hour post-injection
period.
Risk and Complications
DYSPORT treatment of frown lines can cause minor temporary droop of
one eyelid inapproximately 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.
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 DYSPORT injected by Daniela Bobsin, RN. I
am aware if I DO NOT follow strictly Daniela Bobsin’s, RN posttreatment
instructions, I take the risk of complications.
I HEREBY ACKNOWLEDGE THAT I HAVE FULLY DISCLOSED, TO THE
BEST OF MY KNOWLEDGE, MY COMPLETE MEDICAL HISTORY AND
HAVE ANSWERED ALL QUESTIONS IN THE MEDICAL HEALTH
QUESTIONNAIRE A HONESTLY AND ACCURATELY AS POSSIBLE.
DANIELA BOBSIN BEAUTY MEDICAL AESTHETICS IS NOT
RESPONSIBLE FOR ANY ADVERSE EVENTS THAT OCCUR AS A
RESULT OF FAILURE TO DISCLOSE HEALTH INFORMATION AS
REQUESTED.
I acknowledge that I have had the opportunity to consult with Daniela
Bobsin,