Botulinum Toxin A Consultation and Consent Form

Client Details

Botulinum Toxin A is NOT recommended for pregnant, or breastfeeding women.


Side Effects

This list is not meant to be inclusive of all possible risks associated with Botulinum Toxin A as there are both known and unknown side effects associated with any medication or procedure.
The possible side effects of Botulinum Toxin A include, but are not limited to:
- Allergic reactions
- Rash
- Itching
- Neck or back pain
- Difficulty swallowing
- Shortness of breath
- Nausea
- Diarrhea
- Stomach pain
- Loss of appetite
- Muscle weakness where the medicine was injected
-Injection site reactions - i.e. bruising, bleeding, pain, redness, swelling, infection or tenderness
- Flu symptoms - i.e. fever or feeling feverish/chills, cough, sore throat, runny/stuffy nose, muscle/body aches, headaches, fatigue
- Dizziness
- Dry mouth
- Dry, itchy, or watery eyes
- Increased sensitivity to lights
- Ringing in your ears
- Increased sweating in areas other than the underarms
- Eyelid swelling or bruising

Please note: Most people will have slightly swollen, pinkish bumps where the injections went in, for a couple of hours or even several days after the treatment.

If you have concerns about any side effects please seek medical advice.


Consent

Please tick each box to show your understanding and agreement:

Injection of Botulinum Toxin A into the small muscles between the brows causes those specific muscles to halt their function (be paralyzed) thereby improving the appearance of the wrinkles.

I understand the goal is to decrease the wrinkles in the treated area. This paralysis is temporary and re-injection is necessary within three to four months. It has been explained to me that other temporary and more permanent treatments are available.

As Botulinum Toxin A is not an exact science, there might be an uneven appearance of the face with some muscles more affected by the Botulinum Toxin A than others. In most cases this uneven appearance can be corrected by injecting Botulinum Toxin A in the same, or nearby muscles. However in some cases this uneven appearance can persist for several weeks or months.

Additionally the number of units injected is an estimate of the amount of Botulinum Toxin A required to paralyze the muscles. I understand there is no guarantee of results of any treatment.

I understand the regular charge applies to all subsequent treatments.

I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment.

By signing below I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks.

I hereby give consent to perform this and all subsequent Botulinum Toxin A treatments with the above understood.

I hereby release the practitioner injecting the Botulinum Toxin A and the facility from liability associated with this procedure.



Tap or click on the signature above to sign


Appointment Guidance

If you have tested positive for COVID-19, or have any symptoms of COVID-19 (see below) please do not attend your appointment. Please contact us as soon as you know you will be unable to attend so we can reschedule.

COVID-19 Symptoms:

  • a high temperature or shivering (chills) – a high temperature means you feel hot to touch on your chest or back (you do not need to measure your temperature)
  • a new, continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours
  • a loss or change to your sense of smell or taste
  • shortness of breath
  • feeling tired or exhausted
  • an aching body
  • a headache
  • a sore throat
  • a blocked or runny nose
  • loss of appetite
  • diarrhoea
  • feeling sick or being sick
SUBMIT

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