This informed consent form is to provide written information regarding the risks, benefits, and alternatives of the procedure you are about to undertake. This material serves as a supplement to the discussion you have with your doctor/healthcare/medical provider. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing the consent form.
BRUXISM treatment often involves the use of botulinum toxin injections to relax the muscles responsible for clenching and grinding the teeth, typically the masseter and/or temporalis muscles. This treatment can help alleviate symptoms such as jaw pain, headaches, and tooth damage caused by excessive clenching or grinding. The injections work by temporarily reducing the activity of these muscles, providing relief and improving overall comfort.
RISKS AND COMPLICATIONS
Understanding the risks is essential. No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate medical attention and/or extended therapy. It has been explained to me that there are certain inherent and potential risks and side effects in any procedure, including but not limited to:
Localized pain, tenderness, or discomfort at the injection site.
Bruising, swelling, or redness at the treated area.
Temporary weakness in nearby muscles, which could affect chewing or facial expressions.
Asymmetry or uneven results.
Allergic reaction to the product or components used.
Mild flu-like symptoms.
Rare complications, including muscle atrophy or unintended relaxation of nearby muscles.
No guarantee of full symptom resolution or desired outcome.
PUBLICITY MATERIALS
I authorise the taking of clinical photographs and videos. I understand that photographs and videos may be taken of me for educational and marketing purposes. I hold the practitioner harmless for any liability resulting from this production. I waive my rights to any royalties, fees, and to inspect the finished production as well as advertising materials in conjunction with these photographs.
RESULTS
Botulinum toxin treatments for bruxism have been shown to be safe and effective. However, the results are temporary, typically lasting between 3-6 months. Additional treatments will be required to maintain the full effects. It is important to note that individual results may vary, and there is no guarantee that the treatment will completely resolve bruxism symptoms. Follow-up treatments may be necessary for optimal management of the condition.
POST-TREATMENT CARE
I have been instructed in and understand the post-treatment instructions. I understand that it may take a few days to one week for the full effects of the treatment to become apparent. Temporary side effects, as outlined above, may occur during this period.
RIGHT TO DISCONTINUE TREATMENT
I understand that I have the right to discontinue treatment at any time. However, I acknowledge that payment for any treatments administered will still be required in full.
PAYMENT
I understand that this is an elective procedure and that payment is my responsibility and is expected at the time of treatment. I understand that this is a non-essential procedure and the procedure has been fully explained to me.
I certify by signing this form that I have read and understood the information provided in this document. All of my questions have been answered satisfactorily. I accept the risks and complications of the procedure, and I understand that no guarantees are implied regarding the outcome. I also confirm that I will notify my healthcare provider of any changes in my medical history.