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Contact Us
Menu
About Us
Premises Inspection Committee Report
Cosmetic Surgeons in the GTA
Setara Ghairat | Nonsurgical Treatment Specialist
Videos
Testimonials
Our Doctors
Dr. Laura Musselman
Dr. William El Masri
Dr. Lawrence B. Cohen
Dr. Brian Yeung, N.D.
Dr. Leonard Bienenstock, M.D.
Dr. Chameli Deb, M.D.
Breast
Breast Augmentation
Male Breast Reduction
Breast Reduction
Before & After (Breast Augmentation)
Face
Facelift
Ulthereapy Non-surgical Facelift
Rhinoplasty | Nose Surgery
Chin Surgery
Eyelid Surgery / Blepharoplasty
Forehead Surgery
Otoplasty / Ear Surgery
Facial Scar Revision Surgery
Jeunesse FUE Hair Transplant
Body
Brazilian Butt Lift [BBL] or Gluteoplasty
Abdominoplasty / Tummy Tuck
Liposuction
Body Makeover Surgery
Vaginal Surgery
Weight Loss
Naturopathic Weight Loss
Lap Band Surgery
Weight Loss With Gastric Balloon
Non-Surgical
Non-surgical Skin Treatments
Fillers & Injectables in Toronto
Treatments
Full Face Lift With Ultherapy
Ulthereapy Non-surgical Facelift
Vitamin Injection Therapy
Skin Rejuvenation Therapy
Jeunesse FUE Hair Transplant Treatment in Toronto
Microdermabrasion Treatment in Toronto
Mole Removal Treatment in Toronto
Anti Aging Bio-Identical Hormone Testing and Replacement (BHTR) Toronto
Photo Facial Treatment in Toronto
Derma Filler Esthelis
Eyelash Extensions in Toronto
Chemical Peels in Toronto
Laser Hair Removal
Authoritative Clinical Data, Peer Reviews & White Papers on Laser Hair Removal
Before & After
Blogs
Pricing
Our Pricing
FAQ’s
Cancellation Policy
Forms
La Fontaine Source De Jeunesse
Patient Health/Anesthesia Questionnaire
COVID-19 Questionnaire & Informed Consent – General
Day of Surgery COVID-19 Questionnaire & Informed Consent
Option Weight Loss Clinic
Dermal Filler Informed Consent
Injectable Informed Consent Form
Consent for Sclerotherapy of Varicose and Spider Veins
Contact Us
416-962-4444
About Us
Premises Inspection Committee Report
Cosmetic Surgeons in the GTA
Setara Ghairat | Nonsurgical Treatment Specialist
Videos
Testimonials
Our Doctors
Dr. Laura Musselman
Dr. William El Masri
Dr. Lawrence B. Cohen
Dr. Brian Yeung, N.D.
Dr. Leonard Bienenstock, M.D.
Dr. Chameli Deb, M.D.
Breast
Breast Augmentation
Male Breast Reduction
Breast Reduction
Before & After (Breast Augmentation)
Face
Facelift
Ulthereapy Non-surgical Facelift
Rhinoplasty | Nose Surgery
Chin Surgery
Eyelid Surgery / Blepharoplasty
Forehead Surgery
Otoplasty / Ear Surgery
Facial Scar Revision Surgery
Jeunesse FUE Hair Transplant
Body
Brazilian Butt Lift [BBL] or Gluteoplasty
Abdominoplasty / Tummy Tuck
Liposuction
Body Makeover Surgery
Vaginal Surgery
Weight Loss
Naturopathic Weight Loss
Lap Band Surgery
Weight Loss With Gastric Balloon
Non-Surgical
Non-surgical Skin Treatments
Fillers & Injectables in Toronto
Treatments
Full Face Lift With Ultherapy
Ulthereapy Non-surgical Facelift
Vitamin Injection Therapy
Skin Rejuvenation Therapy
Jeunesse FUE Hair Transplant Treatment in Toronto
Microdermabrasion Treatment in Toronto
Mole Removal Treatment in Toronto
Anti Aging Bio-Identical Hormone Testing and Replacement (BHTR) Toronto
Photo Facial Treatment in Toronto
Derma Filler Esthelis
Eyelash Extensions in Toronto
Chemical Peels in Toronto
Laser Hair Removal
Authoritative Clinical Data, Peer Reviews & White Papers on Laser Hair Removal
Before & After
Blogs
Pricing
Our Pricing
FAQ’s
Cancellation Policy
Forms
La Fontaine Source De Jeunesse
Patient Health/Anesthesia Questionnaire
COVID-19 Questionnaire & Informed Consent – General
Day of Surgery COVID-19 Questionnaire & Informed Consent
Option Weight Loss Clinic
Dermal Filler Informed Consent
Injectable Informed Consent Form
Consent for Sclerotherapy of Varicose and Spider Veins
Contact Us
Menu
About Us
Premises Inspection Committee Report
Cosmetic Surgeons in the GTA
Setara Ghairat | Nonsurgical Treatment Specialist
Videos
Testimonials
Our Doctors
Dr. Laura Musselman
Dr. William El Masri
Dr. Lawrence B. Cohen
Dr. Brian Yeung, N.D.
Dr. Leonard Bienenstock, M.D.
Dr. Chameli Deb, M.D.
Breast
Breast Augmentation
Male Breast Reduction
Breast Reduction
Before & After (Breast Augmentation)
Face
Facelift
Ulthereapy Non-surgical Facelift
Rhinoplasty | Nose Surgery
Chin Surgery
Eyelid Surgery / Blepharoplasty
Forehead Surgery
Otoplasty / Ear Surgery
Facial Scar Revision Surgery
Jeunesse FUE Hair Transplant
Body
Brazilian Butt Lift [BBL] or Gluteoplasty
Abdominoplasty / Tummy Tuck
Liposuction
Body Makeover Surgery
Vaginal Surgery
Weight Loss
Naturopathic Weight Loss
Lap Band Surgery
Weight Loss With Gastric Balloon
Non-Surgical
Non-surgical Skin Treatments
Fillers & Injectables in Toronto
Treatments
Full Face Lift With Ultherapy
Ulthereapy Non-surgical Facelift
Vitamin Injection Therapy
Skin Rejuvenation Therapy
Jeunesse FUE Hair Transplant Treatment in Toronto
Microdermabrasion Treatment in Toronto
Mole Removal Treatment in Toronto
Anti Aging Bio-Identical Hormone Testing and Replacement (BHTR) Toronto
Photo Facial Treatment in Toronto
Derma Filler Esthelis
Eyelash Extensions in Toronto
Chemical Peels in Toronto
Laser Hair Removal
Authoritative Clinical Data, Peer Reviews & White Papers on Laser Hair Removal
Before & After
Blogs
Pricing
Our Pricing
FAQ’s
Cancellation Policy
Forms
La Fontaine Source De Jeunesse
Patient Health/Anesthesia Questionnaire
COVID-19 Questionnaire & Informed Consent – General
Day of Surgery COVID-19 Questionnaire & Informed Consent
Option Weight Loss Clinic
Dermal Filler Informed Consent
Injectable Informed Consent Form
Consent for Sclerotherapy of Varicose and Spider Veins
Contact Us
Injectable Informed Consent Form
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I understand that I will be injected with Botulinum A Toxin (Botox) in the area of the glabella muscles to paralyze these muscles temporarily or in the forehead or crows feet around the lateral area of the eyes. Botulinum A Toxin (Botox) injection has been FDA approved for use in the cosmetic treatment for glabellar frown lines only – the wrinkles between the eyebrows. Injection of Botox into the small muscles between the brows causes those specific muscles to halt their function (be paralyzed), thereby improving the appearance of the wrinkles. I understand the goal is to decrease the wrinkles in the treated area. This paralysis is temporary, and re-injection is necessary within three to four months. It has been explained to me that other temporary and more permanent treatments are available. The possible side effects of Botox include but are not limited to: Risks: I understand there is a risk of swelling, rash, headache, local numbness, pain at the injection site, bruising, respiratory problems, and allergic reaction. Infection: Infections can occur which in most cases are easily treatable but in rare cases a permanent scarring in the area can occur. Most people have lightly swollen pinkish bumps where the injections went in for a couple of hours or even several days. Although many people with chronic headaches or migraines often get relief from Botox, a small percent of patients get headaches following treatment with Botox for the first day. In a very small percentage of patients these headaches can persist for several days or weeks. Local numbness, rash, pain at the injection site, flu like symptoms with mild fever, back pain. Respiratory problems such as bronchitis or sinusitis, nausea, dizziness, and tightness or irritation of the skin. Bruising is possible anytime you inject a needle into the skin. This bruising can last for several hours, days, weeks, months and in rare cases the effect of bruising could be permanent. While local weakness of the injected muscles is representative of the expected pharmacological action of Botox, weakness of adjacent muscles may occur as a result of the spread of the toxin. Treatments: I understand more than one injection may be needed to achieve a satisfactory result. Another risk when injecting Botox around the eyes included corneal exposure because people may not be able to blink the eyelids as often as they should to protect the eye. This inability to protect the eye has been associated with damage to the eye as impaired vision, or double vision, which is usually temporary. This reduced blinking has been associated with corneal ulcerations. There are medications that can help lift the eyelid; however, if the drooping is too great the eye drops are not that effective. These side effects can last several weeks or longer. This occurs in 2-5 percent of patients. I will follow all aftercare instructions as it is crucial I do so for healing. As Botox is not an exact science, there might be an uneven appearance of the face with some muscles more affected by the Botox than others. In most cases this uneven appearance can be corrected by injecting Botox in the same or nearby muscles. However, in some cases this uneven appearance can persist for several weeks or months. This list is not meant to be inclusive of all possible risks associated with Botox as there are both known and unknown side effects associated with any medication or procedure. Botox should not be administered to a pregnant or nursing woman. Additionally, the number of units injected is an estimate of the amount of Botox required to paralyze the muscles. I understand there is no guarantee of results of any treatment. I understand the regular charge applies to all subsequent treatments. I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I further agree in the event of non-payment, to bear the cost of collection, and or Court cost and reasonable legal fees, should this be required. By signing below, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks. I hereby give consent to perform this and all subsequent Botox treatments with the above understood. I hereby release the doctor, the person injecting the Botox and the facility from liability associated with this procedure.
Date:
Consent
By initiating this form, I confirm that my answers are true and have been answered to the best of my ability.
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