PATIENT INFORMED CONSENT FOR NEUROTOXIN & DERMAL FILLER INJECTION

I authorize {{provider_name}}, a licensed medical professional at {{clinic_name}}, to perform the injection of neurotoxin (Botox®, Dysport®, Xeomin®, or Jeuveau®) and/or dermal filler (hyaluronic-acid based) into the treatment areas discussed.

RISKS I UNDERSTAND MAY OCCUR:
• Bruising, swelling, redness, tenderness at injection sites
• Temporary asymmetry, ptosis (eyelid or brow droop), or unintended muscle weakness
• Rare: vascular occlusion, tissue necrosis, blindness, or infection
• Rare: allergic reaction; delayed hypersensitivity nodules; Tyndall effect (fillers)
• Non-response or under-response requiring re-treatment

I CONFIRM THAT I AM NOT:
• Pregnant, breastfeeding, or trying to conceive
• Taking blood thinners without physician approval
• Currently ill with active infection, cold sore, or skin condition at injection site
• Allergic to lidocaine, hyaluronidase, or eggs (if applicable)

I understand results are temporary (3–6 months for neurotoxin, 6–24 months for filler) and that touch-ups may be needed. No refunds for administered product.

Patient signature: _______________________  Date: __________
Provider signature: ______________________  Date: __________