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2336 Sylvan Ave #C, Modesto, CA 95355.  (209) 551-1888

Dr. Calvin Lee's Filler / Botox Consent

Your Name:  ___________________________________  

Hello!  Feel free to read this before your visit.  I will go over this document again with you in person and please ask me questions.


In some cases I would need to take your pictures.  Many times it is needed for my own improvement and discussion with Plastic Surgeon Dr.Wu.  And sometimes it is needed for post procedure discussions with you.  If you have something very interesting or may be of use for other patients or medical professionals we would love to show them because sometimes it is easier to explain things with pictures than with words only.

>  Can I (Dr. Lee) take your picture for confidential medical use (improvement/comparison)?     Yes    or    No     
>  Can I show your picture to other patients or medical professionals?  ________
>  Can we use your picture in advertisements including the internet?  ________
                       (we generally do not do this, but in case the opportunity arises, I thought I'd ask.)

FDA off-label usage by physicians

The FDA recognizes that off-label use of drugs by physicians is often appropriate and may represent the standard of medical practice.  Botox (a neuromodulator) and Juvederm (a filler) are FDA approved medications.  Once approved, a drug or product may be prescribed by a licensed physician for any use that, based upon the physician’s professional opinion, is deemed to be safe and effective.  For cosmetic botox, it has only been tested and approved for the wrinkles between the eyes.  Juvederm's testing and approval has only been done in the nasolabial folds (upper part of the "parenthesis" around the mouth/nose area).  You may be here and have heard of Botox/Juvederm being injected in other areas.  These areas are called "off-label" usage of Botox and Fillers (such as crows feet, forehead, lips, neck, jowels and chin).

Safety & Risks of Botox and Fillers

Tests haven't been done regarding Botox, Fillers, Latisse, and Obagi.  The required testing for these substances to be called "safe" during pregnancy probably couldn't be done because of the difficulty finding pregnant volunteers who would like to experiment on themselves and their baby.  It is our preference to take no chances with pregnancy.  If you know that you are pregnant, please alert me (Dr. Lee) or Dr. Wu.

>  Are you pregnant?  _______

Allergic reactions can occur to any medication.  Botox and Juvederm (fillers) are considered medications.

There is a risk of drooping eyelids, drooping eyebrows, double vision, headaches, and difficulty breathing.  We know many techniques to minimize these, but the risks are still present.

Bruising and swelling are common with filler procedures.

Unevenness with Botox and Fillers (ie. Juvederm) is possible.  In fact, if we look very closely at ourselves we are almost always uneven.  The two sides of our bodies are like sisters/brothers, not identical twins.

There is the risk of inadequate and/or unsatisfactory result.  Individuals need different amounts of Botox or Fillers.  It is also possible that at different times in our lives we have different reactions to medications - thus effective dosages can change too.  Sometimes this can be easily addressed with more product.  There will be an additional fee for such "touch ups." 

Infection, bleeding, bruising, and swelling are possible risks with any surgical procedure.  There is also the risk of damages to deeper structures such as blood vessels, eye, throat, lung and nerves.  We consider Botox and Filler injections to be surgical procedures.

Regarding cold sore outbreaks around the outside of the mouth, we may consider giving you a prescription of acyclovir.  If you already have cold sores, sometimes stress and procedures around the mouth can bring out a recurrence (which most likely won't affect the eventual outcome).

>  Do you have cold sores around the outside of your mouth?  _______

There are no guarantees in medicine except that I will try my best.  And if you were to get a complication, I will continue to try my best to help you through any problem that may arise.

Calvin Lee, MD
Board Certified General Surgeon

Procedure(s) I would like to have done: 



I have read and understood the above two pages: 


Sign:  ____________________________________  Date: _______________

Visit the Surgical Artistry Botox webpage:    © Calvin Lee, MD May 21, 2012 all rights reserved.