ALLERGAN BOTOX CONSENT FORM PDF

What is Allergan BrandBox? botox-logo Presentations, brochures, questionnaires, and forms to make discussions with patients faster, clearer, and more. Botox is a brand name for botulinum toxin type A, a neurotoxin that blocks Note : This form is intended as a sample form of the information that you as the. Botox therapy for wrinkles is an FDA approved injection treatment designed to weaken the muscle to provide temporary relief of moderate to severe facial.

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The official site for up-to-date tools and training materials for your practice and patients. Once you register, you’ll be able to download resouces for:. Presentations, brochures, questionnaires, and forms to make discussions with patients faster, clearer, and more productive. Emails, counter cards, and brochures you can easily personalize with specific offers and contact information.

Online lessons to help increase your practice’s knowledge and comfort with Allergan products. These may include asthenia, boto muscle weakness, diplopia, ptosis, dysphagia, dysphonia, dysarthria, urinary incontinence and breathing difficulties.

These symptoms have been reported hours to weeks after injection. Swallowing and breathing difficulties can be life threatening and there have been reports of death.

The risk of symptoms is probably greatest in children treated for spasticity but symptoms bohox also occur in adults treated for spasticity and other conditions, particularly in those patients who have an underlying condition that would predispose them to these symptoms. In unapproved uses, including spasticity in children, and in approved indications, cases of spread of effect have been reported at doses comparable to those used to treat cervical dystonia and spasticity and at lower doses.

In several of the cases, patients had pre-existing dysphagia or other significant disabilities. These reactions include anaphylaxis, serum sickness, urticaria, soft-tissue edema, and dyspnea. One fatal case of anaphylaxis has been reported in which lidocaine was used as the diluent and, consequently, the causal agent cannot be reliably determined.

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Some of these patients had risk factors including pre-existing cardiovascular disease. Use caution when administering to patients with pre-existing cardiovascular disease. Increased Risk of Clinically Significant Effects with Pre-existing Neuromuscular Disorders Individuals with peripheral motor neuropathic diseases, amyotrophic lateral sclerosis, or neuromuscular junction disorders eg, myasthenia gravis or Lambert-Eaton syndrome should be monitored when given botulinum toxin.

Patients with neuromuscular disorders may be at increased risk of clinically significant effects including generalized muscle weakness, diplopia, ptosis, dysphonia, dysarthria, severe dysphagia, and respiratory compromise from onabotulinumtoxinA see Warnings and Precautions.

Patients with pre-existing swallowing or breathing difficulties may be more susceptible to these complications.

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In most cases, this is a consequence of weakening of muscles in the area of injection that are involved in breathing or oropharyngeal muscles that control swallowing or breathing see Boxed Warning. Human Albumin and Transmission of Viral Diseases This product contains albumin, a derivative of human blood. Based on effective donor screening and product manufacturing processes, it carries an extremely remote risk for transmission of viral clnsent and variant Creutzfeldt-Jakob disease vCJD.

There is a theoretical risk for transmission of Creutzfeldt-Jakob disease CJD donsent, but if that risk actually exists, the risk of transmission would also be considered extremely remote.

No cases of transmission of viral diseases, CJD or vCJD have ever been identified for licensed albumin or albumin contained in other licensed products.

Botox Consent Form

The effect of administering different botulinum neurotoxin products at the same time or within several months of each other is unknown. Excessive neuromuscular weakness may be exacerbated by administration of another botulinum toxin prior to the resolution of the effects of a previously administered botulinum toxin. This product is intended for single patient one-time use only.

WARNINGS Processing of the tissue, laboratory testing, and careful donor botxo minimize the risk of the donor tissue transmitting disease to the recipient patient. Discard all open and unused portions of the product in accordance with standard medical practice and institutional protocols for disposal of human tissue. Once a package or container seal has been compromised, the tissue shall be either transplanted, if appropriate, or otherwise discarded. DO NOT use if the foil pouch is opened or damaged.

DO NOT use if the seal is broken or compromised.

Botox Consent Form

DO NOT place the foil pouch bbotox the sterile field. When applied as an obtox, it is recommended that the dermal side be placed allerggan the most vascular tissue. If any hair is visible, remove using aseptic technique before implantation.

DO NOT use if this product is dry. Use of this product is limited to specific health professionals e. Certain considerations should be made to reduce the risk of adverse events when performing surgical procedures using a tissue graft. To report an adverse reaction, please call Allergan at 1. It is also FDA-cleared to affect the appearance of lax tissue with submental area treatments. During the procedure the patient may experience pinching, numbness, or discomfort.

Following the procedure, typical side effects include temporary numbness, redness, swelling, bruising, firmness, tingling, stinging, and pain. Rare side effects may also occur. As with any medical procedure, a consultation should be done by a licensed physician to determine if the patient is a candidate for treatment. Treatment applications that deviate from the guidelines are not recommended.

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Onset and duration may vary among individuals and may persist. Consider withholding subsequent treatments until resolution. Injection Site Ulceration and Necrosis Injections that are too superficial into the dermis may result in skin ulceration and necrosis. Increased iris pigmentation has occurred when bimatoprost solution was administered.

Patients should be advised about the potential for increased brown iris pigmentation, which is likely to be permanent. Bimatoprost has been reported to cause pigment changes darkening to periorbital pigmented tissues and eyelashes. The pigmentation is expected to increase as long as bimatoprost is administered, but has been reported to be reversible upon discontinuation of bimatoprost in most patients.

The most frequently reported adverse events were eye pruritus, conjunctival hyperemia, skin hyperpigmentation, ocular irritation, dry eye symptoms, and periorbital erythema.

Other potential adverse events that may occur with breast implant surgery foorm For more information see the full Directions for Use at www. This system should be used with a legally marketed vacuum or aspirator apparatus as a source of suction.

If harvested fat is to be re-implanted, the harvested fat is only to be used without any additional manipulation. Do not use the product if sterile packaging is damaged.

This device will not, in and of itself, produce significant weight reduction. This device should be used with extreme caution in patients with chronic medical conditions such as diabetes, heart, lung, or circulatory system disease or obesity.

Use of this device is limited to those physicians who, by means of formal professional training or sanctioned continuing medical education including supervised operative experiencehave attained proficiency in suction lipoplasty and tissue transfer. Results of this procedure will vary depending upon patient age, surgical site, and experience of the physician.

Results of this procedure may or may not be permanent. The amount of fat removed should be limited to that necessary to achieve a desired cosmetic effect. Filling the device with adipose tissue over the maximum fill volume bofox can lead allregan occlusion of the mesh resulting in mesh tear.

Patients should use a sunscreen, wear protective clothing, and limit sun exposure while using these products or this system and for a week following discontinuation.

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Terms of Use Privacy Policy Unsubscribe. Official assets and educational materials. Want access to BrandBox? What is Allergan BrandBox? Once you register, you’ll be able to download resouces for: Customizable Materials Office Allergwn.