What is Allergan BrandBox? botox-logo Presentations, brochures, questionnaires, and forms to make discussions with patients faster, clearer, and more. Botox is a brand name for botulinum toxin type A, a neurotoxin that blocks Note : This form is intended as a sample form of the information that you as the. Botox therapy for wrinkles is an FDA approved injection treatment designed to weaken the muscle to provide temporary relief of moderate to severe facial.

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Please follow the exact formatting in this example in order to successfully upload your patient list.

Once you register, you’ll be able to download resouces for: Swallowing and breathing difficulties can be life threatening, and there have been reports of death. It is also FDA-cleared to affect the appearance of lax tissue with submental area treatments. Successfully Created Prior Authorization Request.

Some of these patients had risk factors including cardiovascular disease. Based on effective donor screening and product manufacturing processes, it carries an extremely remote risk for transmission of viral diseases and variant Creutzfeldt-Jakob disease vCJD. In clinical trials, Last Name Required This information is required. Would you like to add another patient? Use this form to record patient symptoms, dosing, ocnsent site, and follow-up for your Cervical Dystonia patients.

Program Forms

Instruct patients to contact cosnent physician if they experience difficulty in voiding as catheterization may be required. Register now to initiate benefits verifications, conduct prior authorizations, and manage the reimbursement process from start to finish. To ensure your consnt is successful, please make sure the format follows the template exactly. This information is not meant to alarm you, but to better inform you so that you may give or withhold your consent for the treatment of your cosmetic condition as well as help you formulate additional questions which may not have been covered in consultation.

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Allergan BrandBox – Official Assets and Educational Materials

Emails, counter cards, and brochures you can easily personalize with specific offers and contact information. Terms of Use Privacy Policy Unsubscribe. A charge will be made for each treatment session. You have not entered any information in 20 minutes.

ALLERGAN BOTOX CONSENT FORM PDF

This results in the relaxation of the muscle and improvement of the lines and wrinkles that the targeted muscle action produced or improved contour of the face. I agree to follow up with Dr. During the procedure the patient may experience pinching, numbness, or discomfort.

In unapproved uses, including spasticity in children, and in approved indications, cases of spread of effect allergwn been reported at doses comparable to those used to treat Cervical Dystonia and spasticity and at lower doses.

Last Name Required This information is required. My questions have been fully answered and I have read or have had read to me this document, consenr not taken any medications alllergan may impair my mental ability, do not feel rushed or under pressure and understand its contents.

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An error has occurred, and our IT staff has been notified. Preferred Method of Contact Email Phone. Xonsent Name Required This information is required. Treatment applications that deviate from the guidelines are not recommended. This product is intended for single patient one-time use only.

Excessive neuromuscular weakness may be exacerbated by administration of another botulinum toxin prior to the resolution of the effects of a previously administered botulinum toxin. A Business Practice Specialist will contact you within business days. Lorem upsum dolro sit amet, consectetur adipisicing elit, sed to eiuysmode tempor.

Thank you for your inquiry. Individuals with peripheral motor neuropathic diseases, amyotrophic lateral sclerosis ALSor neuromuscular junction disorders eg, myasthenia gravis or Lambert-Eaton syndrome should be monitored when given botulinum toxin.

These may include asthenia, generalized muscle weakness, diplopia, ptosis, dysphagia, dysphonia, dysarthria, urinary incontinence and breathing difficulties. No cases of transmission of viral diseases, CJD, or vCJD have ever been identified for licensed albumin or albumin contained in other licensed products.

The effect of administering different botulinum neurotoxin products at the same time or within several months of each other is unknown. Error Creating Prior Authorization Request. Results of this procedure may or may not be permanent.