Botulinum Toxin Consultation/Consent Form | Aesthetics Forms Portal

Botulinum Toxin Consultation and Consent Form

Client Details

Full Name: *

Date of Birth: *

Contact Number: *

Email: *

Medical History

Are you currently receiving any medical treatment? *

Please list: *

Do you have any medical conditions? *

Please list: *

Are you currently taking any medications? *

Please list: *

Do you have any allergies? *

Please list: *

Are you (or is there a possibility you may be) pregnant, or are you breastfeeding? *

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

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide more detail: *

Have you previously had any Dermal Filler or Botulinum Toxin? *

Which treatment did you receive, what areas were treated and when? *

Have you previously received any other aesthetic treatments (e.g. Laser, Peels, Dermabrasion etc.)? *

Which treatment did you receive, what areas were treated and when? *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Your Treatment

What would you like to improve or change about your appearance? *

Possible Side Effects

This list is not meant to be inclusive of all possible risks associated with Botulinum Toxin as there are both known and unknown side effects associated with any medication or procedure.

The possible side effects of Botulinum Toxin include, but are not limited to:

- Allergic reactions
- Headache
- Temporary drooping of facial features
- Double or blurred vision
- Asymmetry
- Neck or back pain
- Difficulty swallowing
- Muscle weakness where the medicine was injected
- Injection site reactions - i.e. bruising, bleeding, pain, redness, swelling, infection or tenderness
- Flu symptoms
- Dizziness
- Dry, itchy, or watery eyes
- 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.

Aftercare Advice

Please read carefully.

The goal of aftercare is to encourage optimal treatment results. It can also minimize the risk of bruising and spreading to other areas. Follow the aftercare advice provided for optimal results.

Don’t touch your skin. Take a break from makeup for 24 hours and don't touch your face. Applying makeup will rub the skin, potentially dispersing the toxin. If you got Botulinum Toxin in another part of your body, you should also avoid touching those areas. This includes professional massages on the treated areas. It’s best to schedule your next massage several days later.
Wait 24 hours to exercise. If exercise is part of your daily routine, wait at least 24 hours to work out. Physical activity increases blood flow. This could potentially spread the toxin to unintended areas and reduce its effectiveness at the injection site. It also increases the risk of bruising. Exercise also contracts your muscles, which may decrease the toxin’s effectiveness.
Sit up. Sit up for the first 4 hours after getting Botulinum Toxin. Bending or lying down might spread the toxin and promote bruising.
Medication. Some medications might increase your risk of bruising. Be sure to ask your practitioner when it’s safe to start taking them again. Avoid aspirin and ibuprofen for a few days following treatment. Do not restart Retinol or Retin-A for 2 days.
Don’t drink alcohol. Alcohol increases the risk of bruising. Wait at least 48 hours after your treatment before consuming alcohol.
Don't massage, rub or apply pressure to the treated area.
Don’t sleep on the treated areas. Try your best to avoid sleeping on the injected areas. This will minimize the physical pressure and let the Botulinum Toxin settle into your muscles. Also, avoid sleeping within 4 hours after your procedure.
Stay out of the sun. Avoid sun exposure for at least 48 hours. The heat can promote flushing and increase your blood pressure, which may encourage bruising.
Avoid heat exposure. It’s also best to avoid other forms of heat exposure, such as: Tanning bed, Hot tubs, Hot showers or baths and Saunas.
Apply ice. You can apply a pack of ice for relief. The bruising should go away in about 2 weeks.
Apply topical cream. You can apply Arnica cream to any areas with redness, bruising or swelling.
Avoid waxing and use of chemical depilatories for 1 week following treatment.
Wait before having more Aesthetic treatments. Avoid facials, chemical peels, micro-dermabrasion for 2 weeks following treatment. Radio frequency miconeedling must be avoided for 4 weeks.

Please tick the box to confirm: *

I have read and understood the aftercare advice given to me on this form.

Consent

I accept that any treatment I am going to receive is at my own risk.

I certify that I have read, fully understood, and completed this form to the best of my knowledge.

I understand that failure to disclose information requested above may result in adverse side effect(s), unknown because of this to which I accept full liability/responsibility.

The treatment(s) and possible side effect(s) have been fully explained to me.

I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request.

I accept that if I am not satisfied with the treatment I will inform the practitioner immediately.

I fully understand the above and consent to receive Botulinum Toxin.

Client Signature: *

Tap or click on the signature above to sign

Clinic to Complete

Face Draw

Notes:

Grayscale	Invert	Sepia
Sepia2	Blur	Sharpen
Emboss