Ronald E. Reece, MD
Board Certified - American Board of Dermatology
For a Consultation call 530-246-0236
Dr. Reece offers BOTOX® for the relief of wrinkles. Below is the consent form used. It will probably address most of the common questions the patient asks about the procedure.
You have the right to be informed about your skin condition and treatment so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to better inform you so that you may give or withhold your consent for the treatment program. I have requested that Dr. Ronald Reece attempt to improve my facial expression lines with Botox. This is the trademark for botulinum toxin. BOTOX® has been used for more than a decade in children and adults to improve muscle spasms of the facial muscles. The toxin is a purified protein. BOTOX® injections weaken muscles, thereby relaxing frown lines, crow's feet and other expression lines.
BOTOX® is a cumulative treatment and your treatments will have better effects after several treatments than after a single treatment.
The solution is injected with a small needle into the muscle. You see the benefits develop over the next five to seven days. Less frowning will be possible.
Side effects and complications are unusual but possible. Occasionally, slight swelling, and/or bruising may last for several days after the injections. Rarely, an adjacent muscle may be weakened for several weeks after an injection. This may cause difficulty in raising my eyelid or double vision. Headaches and flu-like symptoms may also occur following BOTOX® injections. Less likely but possible complications include infection, nerve damage, skin necrosis (dead skin which may leave scars and/or necessitate skin grafting and anaphylaxis (allergic reaction) including death. I have been advised of the risks involved is such treatment, the expected benefits of such treatment, and alternative treatments including no treatment at all.
I understand that several sessions may be needed to complete the injection series and the multiple sessions are planned I understand that there is a separate charge for any subsequent treatments.
I agree that this constitutes full disclosure, and that is supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs, and that I have had sufficient opportunity for discussion and to ask questions.
I give Dr. Ronald Reece permission to use photographs of me for education and/or publicity. I will contact you again if photographs will be used for publicity.
Ronald E. Reece M.D.
1. Do not lie down for 4 hours.
If you have any questions or concerns, we are here for you,
BOTOX® is a regestered trrademark of Allergan, INC.