Gulf Coast Facial Plastics & ENT Center

BOTOX INJECTION CONSENT

I authorize Dr. Daube to treat me with Oculinum (Botulinum Toxin Type A), manufactured by Oculinum, Inc. & distributed by Allergan Pharmaceuticals. It has been approved by the Federal Drug & Food Administration (FDA) for treatment of blepharospasm. It’s safety & effectiveness in other spasmodic conditions is still being investigated. There is some discomfort associated with the injection. The potential complications have been explained to me, and may include weakness of the injected muscles and other unknown side effects. In patients treated for blepharospasm, the most common side effects have included droopy eyelids and blurring of vision. In much higher dosages, and only if injected directly into the circulation, there is a remote possibility of potential fatal toxicity. However, precaution will be taken to avoid the serious side effects by using safe dosages, avoiding systemic circulation, and performing repeated clinical evaluation. Thousands of patients have been injected since 1984

without any lasting serious side effects.

My signature below constitutes my acknowledgment that:

· I have read & agree to the foregoing.

· The proposed treatment has been satisfactorily described to me, all my questions have been answered to my satisfaction, and I have the right to ask additional questions at any time during the treatment.

· I hereby agree to follow the directions prescribed by my doctor and will report side effects to the doctor immediately.

· I am free to withdraw from this treatment program at any time and may be terminated from the program by Dr. Daube at his discretion.

I grant this authority and consent voluntarily and with no assurances as to the results.

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Procedure Note

Dr. Daube