Injection of a very small amount of Botox®, a purified toxin produced by the bacterium clostridium botulinum, into the specific muscle causes weakness or paralysis of that muscle. This results in relaxation of the muscle and improvement of the lines or wrinkles that the muscle action has formed.

Anticipated Benefit

Response usually is seen 2-10 days after injection. Typically, the muscle action (and wrinkles) will return in 3-5 months. At this point, a repeat treatment will relax the muscle and soften the lines again.

• I understand that several sessions may be needed to complete the injection series. I understand that there is a separate charge for any subsequent treatment.

Risks and Complications

• Possible side effects include: transient headache, swelling, bruising, pain during injection, twitching, itching, numbness, asymmetry (unevenness), temporary drooping of eyelids or eyebrows. These side effects are rare but have been reported. In a very small number of individuals, the injection does not work as satisfactorily or for as long as usual. Known significant risks have been disclosed, yet the theoretical risk of unknown complications does exist.
• Bruising may occur after Botox injections. Substances that increase the risk of bruising include Vitamin E, aspirin, Motrin and other non-steroidal anti-inflammatory drugs. I understand that if I have taken any of the above within the past 7 days, I have an increased risk of bruising. Bruising is also a significant risk with the use of blood thinning medications such as Coumadin. I understand that if I am taking a blood thinning medication, this treatment may result in significant bruising and may not be recommended.
• I understand that there may be a higher possibility of side effects if I do not follow certain instructions and will adhere to these instructions for at least 4 hours from the time of treatment.

Pregnancy & Neurological Disease

• I understand that there are certain conditions where Botox® treatments are not recommended. These include: Neurological disease, such as myasthenia gravis, pregnancy or breastfeeding. None of the conditions above apply to me.

Your consent and authorization for this elective procedure is strictly voluntary. By signing this informed consent form, you hereby grant authorization to our medical staff to perform and/or to administer any related treatment as may be deemed necessary or advisable in the diagnosis and treatment of your condition.

• The nature and purpose of this elective procedure and the complications and side effects have been fully explained to me. Alternative treatments and their risks and benefits have been explained to me and I understand that I have a right to refuse treatment. I agree to adhere to all safety precautions and instructions after the treatment. I have been instructed in and understand post treatment instructions and have been offered a written copy of them. I understand that no refunds will be given for treatments received. No guarantee has been given by anyone as to the results that may be obtained by this treatment.
• I have read this informed consent and certify that I understand its contents in full. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I have had enough time to consider the information given me and feel that I am sufficiently advised to consent to this procedure. I accept the risks and complications of the procedure. I certify if any changes occur in my medical history I will notify the office.
• I hereby give my voluntary consent to this elective procedure and release the facility, medical staff, and specific technicians from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age and am not under the influence of alcohol or drugs. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.
• I agree, if I should have any questions or concerns regarding my treatment / results I will notify this office at immediately so that timely follow-up and intervention can be provided.

Financial Agreement

I agree that I am financially responsible for the full payment of service provided. Payment is expected at the time of service. I understand these services are non-refundable and that insurance never covers cosmetic procedures. All other fees are calculated on the actual amount of product used to achieve the desired effect. I also understand that there will be an additional fee for touch ups.

Cancellation / No Show Policy

A 48-hour notice is required for any appointment changes or cancellations. A cancellation fee of $100 will be charged for any no shows and for any changes or cancellations made within 48 hours of the appointment day and time.

We respect our Providers’ time as they are booked out weeks to months ahead, and we have a wait list. Last-minute cancellations do not allow us time to fill those gaps.  We appreciate your understanding of our cancellation policy. This will allow the Glow team to continue to provide the highest quality service for you and future clients, as well as valuing our team members’ time.

By scheduling an appointment, you are agreeing to our cancellation/no-show policy and having a credit card on file.

Refund Policy

We do not offer refunds on any services rendered.  Aesthetic results are quite variable from person to person and while we do our best to achieve the desired outcome, it cannot be guaranteed.  Clients are responsible for additional treatments needed to achieve desired results.

Retail Products: We do not offer refunds on products purchased.  Defective products may be exchanged within 14 days for the same product.

No refunds on Gift Card purchases.

Privacy Acknowledgement:

We are required to protect your privacy.

Our Notice of Privacy Policy (NPP) details your rights as a patient and how we may use and/or disclose your protected health information.