Botox/Xeomin/Dysport Cosmetic Patient Consent Form

I authorize Eureka Body Care & Spa to perform neuro-modulator treatments in order to reduce the appearance of my facial wrinkles in the areas treated. I understand that this relaxes the muscles under my skin and therefore reduces the wrinkling caused by muscular contraction. I understand that tiny amounts of the product will be injected into the muscle under my skin and that this will cause my muscles to temporarily relax for approximately three to four months. Although results are commonly predictable and provide a good outcome, I have been informed that the practice of medicine is not an exact science and that no guarantees can be made concerning expected results in my case.

I also understand that it can take up to 10-14 days for the full result to occur, although the benefit may begin to develop within the first few days. I understand that the areas treated will result in a reduction of muscle movement and that there is a no guarantee that wrinkles will be completely erased. I understand that the lines directly under the eyes are not affected.

I understand that side effects or complications are rare and not permanent. Occasionally, slight swelling and/or bruising may last for several days after the injections. Incomplete Block, pain, headache, migration of the neuro-modulator injected, bleeding and bruising, damage to deeper structures such as nerves, blood vessels and the eyeball may be damaged during the course of injection. Eye Disorders, functional and irritative rarely occur following the injections. An adjacent muscle may be weakened for several weeks after the treatment. There is less than 1% change of upper eyelid weakness, which means the top eyelid could droop 1 to 2mm, for a month or more. The droop always resolves.
There is a possibility of a poor or inadequate response .
The effect of the neuro-modulators may be potentiated by amino glycoside antibiotics or other drugs known to interfere with neuromuscular transmission.

I have received post-treatment instructions and I agree to following the recommendations.

I have discussed the treatment with the Nurse Injector Specialist and understand all of the information given to me

I understand and agree to undergo the treatment with Botox Cosmetic, Xeomin Cosmetic or Dysport. I agree that this constitutes full disclosures.
The Spa and/or the individuals working at The Spa shall not be held liable for any damages, injuries, or adverse effects that may occur as a result of receiving services at our establishment after the period of three (3) months has elapsed from the date of service. Regardless of the nature or extent of any such adverse effects, The Spa shall bear no responsibility for any claims arising thereafter. The limitation of liability and waiver of claims as outlined in this document shall apply to all services provided by The Spa, including but not limited to body treatments, injections, massages, facials, laser hair removal, and any other spa services offered by The Spa. By receiving services at The Spa, you acknowledge and accept that any adverse effects or consequences that may arise after the aforementioned three (3) month period shall be your sole responsibility and The Spa and its employees shall be released from any liability. By signing below and continuing to use our services, you confirm that you have read, understood, and agreed to the terms and conditions outlined in this document. I certify that I have read and fully understand the above paragraphs and that I have had sufficient opportunity to discussion and to ask questions.