Dermatology Partners

Neuromodulator Consent (Botox)

Neuromodulator Consent (Botox)

I have been consulted by either Dr. Ruth Tedaldi, Dr. Rachel Herschenfeld, Dr. Carin Litani, Dr. Elissa Lunder, or Dr. Alexandra Price and I consent to having Botox, Dysport, Xeomin, and/or Jeuveau treatment.  I understand that I may be required to be seen for follow-up in 2 weeks, and that I am required to have photographs and/or audio visual taken before, during, and after treatment to be used for my medical records.

Botox, Dysport, Xeomin and Jeuveau are injected with a small needle into the muscle with the aim of inhibiting that muscle’s ability to contract, thereby improving facial lines and appearance.  

I have been informed about this treatment, procedure, indications, expected results and possible side effects.  I understand that I may experience swelling, redness, tenderness, headache, ptosis, heavy brow, pain and/or bruising that may occur for several days following treatment.  I also understand that these symptoms will resolve.  Rarely, an adjacent muscle may be weakened for several weeks following a Botox, Dysport, Xeomin or Jeuveau injection. There is also a risk of injury to the eye and to nearby nerves, blood vessels, and other structures. I have been made aware that with any injection, there is always a risk of bleeding and infection. I have been advised of the risks involved and the expected benefits of my treatment.

Although the results are usually dramatic, I have been informed that the practice of medicine is not an exact science and no guarantees can be or have been made concerning the expected results in my case.

Consent Legal Description:

I am undergoing this treatment of my own free will, and that this procedure is being performed for cosmetic reasons.  I acknowledge that no guarantee can be or has been made as to the exact results of this procedure as stated above.  I further understand that while every precaution will be taken to prevent complications, they can and sometimes do occur although quite rarely.  Therefore, I accept responsibility for any complications that may occur and thereby absolve Dr. Ruth Tedaldi,  Dr. Rachel Herschenfeld, Dr. Carin Litani, Dr. Elissa Lunder, Dr. Alexandra Price and any other individuals involved in rendering this treatment of any blame.  I will not post negative remarks on any Internet sites nor engage in slander.

By signing this document, I am: (1) acknowledging that I have been fully informed about the Botox, Dysport, Xeomin and/or Jeuveau cosmetic procedure for which I have been scheduled; (2) certifying that I have read and fully understand the above statements and have had sufficient opportunity for discussion to have any questions answered; and (3) acknowledging that this document supersedes any previous verbal or written disclosures.

Finally, I understand that the terms of payment require full settlement prior to treatment.




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Signature Certificate
Document name: Neuromodulator Consent (Botox)
lock iconUnique Document ID: 19267a5c04195933a056593aeefdc2242b2f7463
Timestamp Audit
May 15, 2020 10:47 am MDTNeuromodulator Consent (Botox) Uploaded by Dermatology Partners Inc - IP