I hereby authorize Robert L. Fischer, M.D. to treat the following condition(s):

NEUROMUSCULAR DISORDERS SUCH AS BLEPHAROSPASM, STRABISMUS, SPASMODIC DYSPHONIA, TORTICOLLIS OR CERVICAL DYSTONIA, COSMETIC FACIAL LINES/WRINKLES, AND HEMIFACIAL SPASM. "OFF LABEL" USES INCLUDE TREATMENT OF CHRONIC PAIN, MIGRAINE HEADACHES, ABNORMAL MUSCLE TREMORS, EXCESSIVE SWEATING, AND WRITERS CRAMP.

The procedures planned for the treatment of my condition(s) have been explained to me by my physician and are listed below:

BOTULINUM TOXIN (BOTOX) THERAPY

Patient Information:
The botulinum toxin is injected directly into the target muscle in a technique similar to a local anesthetic. The botulinum toxin binds to the nerve ending where the nerve joins the muscle, which prevents the nerve from signaling the muscle to contract. One or two injections are required to treat a small muscle, while four to six injections are needed to treat larger muscle groups. Treatment begins to work in two to four days and shows maximal effect in one to two weeks. The effect of treatment lasts between three to six months when new nerve endings are regenerated. A simple repeat treatment is all that is necessary to maintain the desired effect. Side effects are minimal and usually related to the injection site where redness, bruising, headache, swelling, and/or soreness may occur. Some patients have reported a slight lowering of the eyelid (ptosis), or slight lowering of the forehead (this is temporary and resolves in a few weeks). The most significant problem associated with botulinum toxin therapy is antibody formation when the medication is given too frequently or in larger amounts. Antibody formation makes the toxin ineffective and negates the desired effect. Botox therapy should not be administered during pregnancy, if you are nursing or if you have neurological problems.

Known potential adverse effects include: