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Outine of jpertsch.com BOTOX® (Botulinum Toxin Type A) CONSULTATION
The following consultation form details the information Dr. Pertsch needs to know about you and wishes you to understand before proceeding with BOTOX® treatment: BOTOX® (Botulinum Toxin Type A) CONSULTATION PATIENT NAME: ________________________________________ DATE:____________________ Patient information for Dr. Pertsch: Please answer the following questions and review the following information: Do you have any allergies to medications: __________________________________________________ Medications taken (including for weight loss): ______________________________________________ Have you had Botox previously? Approximately when, by whom, results? ________________________ Previous collagen or other skin treatments, approximate dates: __________________________________ ___________________________________________________________________________________ Previous surgery (including cosmetic surgery)/dates: _________________________________________ ___________________________________________________________________________________ Your personal physicians: ______________________________________________________________ Other medical problems? (Please circle all that apply) bruise easily, heavy bleeding with menstrual cycle, nosebleeds, depression or low feelings, life stress: separation/divorce, work change, loss, psychiatric treatment, hepatitis, cirrhosis, cancer, HIV or AIDS, cold sores, glaucoma, dry eyes, or other vision difficulty. Any other medical or other life problems not mentioned above? _________________________________ ___________________________________________________________________________________ Women only: Is there any chance that you could be pregnant? I.e. unprotected intercourse, irregular or missed periods, nausea or swollen breasts? (If so a pregnancy test should be performed) Yes No
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GENERAL INFORMATION: Realistic expectation is the key to success: Improvement, not perfection. Botulinum A toxin injection is used in the cosmetic treatment of glabellar frown lines (wrinkles between the eyebrows) and other areas. When injected into a muscle it causes temporary paralysis of that muscle. Botulinum A toxin is approved by the Food and Drug Administration (FDA) for the treatment of eyelid spasm, muscle spasm causing crossed eyes, as will as for correcting one-sided facial muscle spasm. Although used for cosmetic treatment of glabellar frown lines and other skin wrinkling, the FDA does not yet approve botulinum A toxin for that purpose. Injection of this material into the small muscles above the nose, between the brows, and other areas causes those specific muscle to halt their function (be paralyzed), thereby improving the appearance of the wrinkles. This paralysis is temporary, and reinjection is necessary within three to five months. The start of reduced muscle activity is occasionally immediate but may take three to seven days to see the full effect. Deeper lines and wrinkles may need other additional treatments (see options below) in addition to botulinum A toxin to achieve the maximum improvement possible. Repeated botulinum A toxin injections over a period of time may result in permanent loss of muscle function. Options for alternative treatment include the injection of collagen, your own fatty tissue, or the surgical removal of the muscles (usually through a brow lift or blepharoplasty incision). There is no medical reason or 'indication' to have wrinkles reduced via Botox or other methods and you may choose to do nothing. Treatments should not be given during pregnancy.
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____ Retin A, other 'fruit' acids ____ Chemical peel or laser resurfacing ____ Botox injection to paralyze muscle ____ Collagen forms: Zyderm I, Zyderm II, Zyplast ____ Fat injection ____ Other injectable material ____ Surgical implants: absorbable, nonabsorbable ____ Surgical reductions: upper/lower blepharoplasty, face/neck lift, brow lift, direct excision of muscle via browlift or blepharoplasty incision. Direct excision of deepest wrinkles or folds ____ Temporary improvement in lines & wrinkles Complications are rare and may include paralysis of nearby muscles resulting in that muscles temporary loss of function (e.g., a drooping upper eyelid). Injection, especially repeated injections theoretically may cause muscle twitching (fasciculation). Other even less frequent problems include double vision, drooping lower eyelid (ectropian), and asymmetric smile (zygomaticus major paralysis).
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GENERAL INSTRUCTIONS BEFORE YOUR TREATMENT: 1. Remove all facial makeup in any area that you may wish to have treated upon arrival to the office. 2. Best to not take aspirin (acetylsalicylic acid) or aspirin-containing products for two weeks prior to your treatment to minimize bruising. Tylenol is best. Motrin, Advil, ibuprofen, naprosyn and other nonsteroidal antiinflammatories (NSAIDS) are also best avoided. Celebrex may be continued.
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1. Wait about 30 minutes before applying makeup. 2. Return to the office immediately if any increasing redness, tenderness, swelling, drainage or any other problem.
Please call Dr. Pertsch's office if there are any other questions or concerns. Appointments: (650) 344-8700 Received by: ___________________________ Date: ____________________ Copy provided to patient by: ______________________ Copy placed in chart by:___________________________
Copyright © 1999 James L. Pertsch, M.D.
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"Dr. James L. Pertsch and I have discussed my problem, namely facial lines and wrinkles. Further, we have discussed the procedure to treat these: injection of botulinum A toxin into the: glabellar muscles above my nose and eyebrow (corrugator muscles) ____ Alternate means of treatment have been discussed including other procedures to correct ____ I understand the goal is to decrease wrinkles . I understand complications are rare but may include paralysis of other nearby muscles, headache, local numbness, rash, and bruising. ____ It has been explained to me that other temporary and more permanent treatments are available (such as fat injection, collagen, or surgical removal of the muscles are available. I understand there is no guarantee of results of any treatment. ____ I understand the FDA has approved botulinum A toxin for other problems concerning muscles of the eye and face but not for this specific cosmetic procedure. ____ I agree to have pre- and postoperative photographs taken for my record and for patient education purposes. My name will not be used on any such photographs. I understand the photos are the property of Dr. Pertsch. ____ I have read this entire information sheet, have had all my questions answered, and authorize Dr. James L. Pertsch, M.D., with or without and assistant, to inject botulinum A toxin into the muscles determined to be appropriate to improve my frown and other wrinkle lines in the areas indicated above. I hereby request, authorize, and give consent to Dr. Pertsch to perform upon me the above named procedures. The treatment I am to undergo has been explained to me in detail. I understand what is to be done and that there are certain calculated risks to be taken. Dr. Pertsch has not made any guarantee to me whatsoever. I understand what has been told to me about my condition and what will be done to me. I agree to allow details of my case reviewed with staff, physicians as necessary for quality control/ peer review purposes. I certify that I have read and understand all of the above pages and that all blank spaces were checked or filled in prior to my signature."
PATIENT:________________________________ DATE: _________________________ CONSULTANT:___________________________ DATE: _________________________ " I certify that I or a member of my staff has discussed all of the above with the patient and have offered to answer any questions regarding the procedure. I believe the patient fully understands the explanation of the procedure and my answers to all of his/her questions" _________________________________________ DATE: _________________________ James L. Pertsch, M.D. Copyright © 1999 James L. Pertsch, M.D. revised 9/16/99
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