pdf, Botox – Treatment for Facial Wrinkles


History of Botulinum Toxin (Botox)
Botox has been used clinically by ophthalmologists and neurologists for over 30 years for the treatment of hemifacial paralysis, blepharospasm, strabismus, etc.  It has been used for the treatment of wrinkles for 25 years. Botox works by temporarily weakening the overactive muscle. Since some wrinkles on the face develop from over use of muscles, they effectively diminish these types of wrinkles. Botox  helps crows feet, frown lines, wrinkles on the forehead, overactive mouth wrinkles and neck bands.


I am aware that weakness does not start for at least 2 days after treatment and is at its maximum until 2 weeks after. Usually the effect lasts four months but may be shorter or longer.

Risks and Complications

Botox treatment of frown lines can cause minor temporary droop of one eyelid in approximately less than 1% of injections.  If this happens, let us know as we can often help. This effect usually lasts 2 weeks but may be up to 2 months. Occasional bruising and transient headache have occurred.
In a very small number of individuals, the injection does not work as satisfactorily or for as long as usual. Pregnancy and Neurologic Disease.  I am not aware that I am pregnant nor that I have any significant neurologic disease.

Please note: The standard dose used to treat each area is 20 units per area.  This dose provides full correction for most patients.  If 2 doses are used over 3 areas, the effect will start to wear of sooner.

Price of Botox:    {Examples of areas for the Botox injections are forehead, in between eyebrows (frown-lines), and both outer corners of eyes (Crow’s Feet)}.  Each area requires 20 units for Botox.

Botox: 1 area- $289 / 2 areas-$459 / 3 areas-$619

Discounts offered for some repeat treatments: 1st Tx full price, 2nd Tx 10% off, 3rd Tx 20% off,  if Txs completed within 1 calendar year.  Recycles each year with same discounts.

I understand that this procedure is cosmetic and payment is my responsibility.  I have read the above and undestand it.  My questions have been answered satisfactorily.  I accept the risks and complication of this procedure.

Patient’s Signature_________________________________________Date________