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    Migraine - Consent Form

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    kala

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    © All Rights Reserved
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    Migraine - Consent Form

    Uploaded by

    kala
    1 views1 page

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    © © All Rights Reserved

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    1 views1 page

    Migraine - Consent Form

    Uploaded by

    kala

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    Updated: 12/27/2023

    Botox® and Xeomin® (Botulinum toxin A) Treatment Patient Consent Form

    The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives of the
    procedure(s) named above. This material serves as a supplement to the discussion you have with your doctor/healthcare provider. It is
    important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the
    procedure, ask your doctor/healthcare professional prior to signing the consent form.

    The Treatment
    The administration of botulinum toxin is accomplished by injecting small amounts into the muscles of the head and neck.
    Botulinum toxin has been approved by the Federal Drug Administration for treatment of chronic migraine. Botulinum toxin does not cure
    chronic migraine, and it may not be effective in some patients.
    Benefits or side effects of botulinum toxin tend to wear off after about 3 months, with a repeat injection required if benefit is to be
    maintained. Injections are usually given every 3 months.
    Botulinum toxin is expensive, and you should be sure of what costs you will incur resulting from the injection.
    Initial ________

    Risks and Complications


    Before undergoing this procedure, understanding the risks is essential. No procedure is completely risk-free. The following risks may
    occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate
    hospitalization, and/or extended outpatient therapy.
    Potential risks and side effects include but are not limited to:
    ● Facial muscle weakness
    ● Reduction or loss of forehead facial animation due to forehead muscle weakness
    ● Head or neck muscle weakness
    ● Head or neck pain
    ● Eyelid drooping
    ● Dry eye. Double vision.
    ● Headache
    ● Fatigue
    ● Allergic reaction. Anaphylaxis.
    ● Injection site reaction: redness, swelling, pain, bruising, itching, etc.
    ● Infection at the injection site
    ● Atrophy and wasting in the muscle injected may occur
    Initial ________

    Pregnancy and Nursing Mothers:


    It is generally believed by many in the medical community that it is unlikely botulinum toxin would harm an unborn baby, enter your milk, or
    harm a breastfed baby. However, reproduction studies have not been performed to determine if botulinum toxin could produce fetal harm to
    an unborn baby, and it is not known if BOTOX can be excreted in human milk.
    Initial ________

    I voluntarily consent to treatment with botulinum toxin injections. The procedure has been fully explained to me. I have read the above and
    understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure and I understand that no
    guarantees are implied as to the outcome of the procedure.

    ___________________________________ ________________________________________ ______________________________________

    Patient Name (Print) Patient Signature Date

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