• From Ophthalmic Mutual Insurance Company (OMIC)

    Note: This form is intended as a sample form of the information that you as the surgeon should personally discuss with the patient. Please review and modify to fit your actual practice. Give the patient a copy and send this form to the hospital or surgery center as verification that you have obtained informed consent.


    Botox is a brand name for botulinum toxin type A, a neurotoxin that blocks messages between muscles and the nerves that control them. The effects of Botox become apparent 2-5 days after injection and generally last for 4-6 months. The FDA has approved the use of Botox to treat facial dystonias (spasms), strabismus (crossed eyes), and to temporarily soften facial rhytids (wrinkles) between the eyebrows. While the FDA has not approved injections to improve the appearance of wrinkles in other areas of the face, physicians may perform these “off-label” procedures. There are alternatives to Botox, including no treatment, or medicines or surgery on my facial nerves and muscles.


    Include but are not limited to:
    1. Bruising
    2. Under correction (not enough effect) or overcorrection (too much effect)
    3. Facial asymmetry (one side looks different than the other)
    4. Paralysis of a nearby muscle leading to: droopy eyelid, double vision, inability to close eye, difficulty whistling or drinking from a straw
    5. Generalized weakness
    6. Permanent loss of muscle tone with repeated injection
    7. Flu-like syndrome or respiratory infection
    8. Nausea or headache
    9. Development of antibodies to Botox
    10. Botox contains human-derived albumin and carries a theoretic risk of virus transmission. There have been no reports of disease transmission through Botox.


    You should not have Botox if:
    you are pregnant; nursing; allergic to albumin; have an infection, skin condition, or muscle weakness at the site of the injection; or have Eaton-Lambert syndrome, Lou Gehrig’s disease, or myasthenia gravis.

    I understand the above, and have had the risks, benefits, and alternatives explained to me. No guarantees about results have been made. I give my informed consent for Botox injections today as well as future treatments as needed.

    Patient signature