Botox® / Dysport® Cosmetic Consent Form

Botox® / Dysport® is injected with a small needle into the muscle, with the aim of inhibiting the underlying muscle contraction, therefore improving facial lines and appearance. Botox® / Dysport® is used to treat wrinkles and dynamic facial lines. The procedure may require a touch-up to achieve your desired results.

I have received a consultation regarding the risks, benefits, and alternatives to BOTOX treatment, and I consent to having Botox® treatment. I have been informed about the treatment, procedure, indications, expected results and possible side effects.

Side effects of Botox® / Dysport® may include, but are not limited to the following:

• Swelling
• Pain
• Headache
• Redness, bruising
• Eyelid or eyebrow drooping
• Failure to achieve your desired results

I agree that this procedure is being performed for cosmetic reasons and that no guarantee can be made as to the exact results of this procedure. I understand that whilst every precaution will be taken to prevent complications and that whilst complications from this procedure are rare, they can and sometimes do occur. I accept responsibility for any complications that may occur. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.


I, the undersigned, have read and understand the information contained within this consent form. My signature indicates that I have read and understand the information in the consent. I hereby release the dermatology office and my physician from all liability associated with this procedure. Furthermore, my signature below indicates my consent to the treatment described and my agreement to comply with the requirements placed on me by this consent form.

Return to the Education Center