Qaesthetics.co.uk

Botulinum Therapy Consent Form
Please initial each section to indicate that you
understand each topic. Do not initial if you desire more
None of the conditions above apply to me. information.
Initials:_____
Proposed Treatment
Limitations and Alternatives
Injection of a very small amount of BoTox®, a purified toxin BoTox® is best at treating dynamic facial lines, those caused produced by the bacterium clostridium botulinum, into the by facial muscle activity; lines present at rest may or may not specific muscle causes weakness or paralysis of that muscle. improve. A treatment may be effective for variable lengths of This results in relaxation of the muscle and improvement of time with subsequent treatments, may not work as well or for the lines or wrinkles that the muscle action has formed. as long as expected, or may not work at all. I have been Initials:_____
informed of other alternatives which exist for the treatment of wrinkles such as topical creams, chemical peels, laser Anticipated Benefit
treatments, surgical removal of the frown muscles, Response usually is seen 2-10 days after injection. forehead/brow lift, facelift, collagen or hyaluronic acid Typically, the muscle action (and wrinkles) will return in 3-5 months. At this point, a repeat treatment will relax the Initials:_____
Initials:_____
Cost/Fees
Payment for this cosmetic procedure is my responsibility. I I understand that several sessions may be needed to understand that there will be an additional fee for touch ups. complete the injection series. I understand that there is a Initials:_____
separate charge for any subsequent treatment. Initials:_____
Follow-up
I agree to follow-up In 2-4 weeks after my first treatment if
Risks and Complications
Possible side effects include: transient headache, swelling, Initials:_____
bruising, pain during injection, twitching, itching, numbness, asymmetry (unevenness), temporary drooping of eyelids or Photographs
eyebrows. These side effects are rare, but have been I authorize the taking of clinical photographs and their use for reported. In a very small number of individuals, the injection scientific purposes both in publications and presentations. I does not work as satisfactorily or for as long as usual. Known understand my identity will be protected. significant risks have been disclosed, yet the theoretical risk Initials:_____
Initials:_____
I have read the above and understand it. My questions
have been answered satisfactorily by the doctor and
Bruising may occur after Botox injections. Substances that doctor’s associates. I accept the risks and
increase the risk of bruising include Vitamin E, aspirin, motrin complications of the procedure.
and other non-steroidal anti-inflammatory drugs. I understand that if I have taken any of the above within the past 7 days, I have an increased risk of bruising. Bruising is also a significant risk with the use of blood thinning medications such as coumadin. I understand that if I am taking a blood thinning medication, this treatment may result in significant bruising and may not be recommended. Initials:_____
I understand that there may be a higher possibility of side effects if I do not follow certain instructions and will adhere to these instructions for at least 4 hours from the time of I will not lie down or bend forward for extended periods of time for at least 4 hours from the time of treatment. I will not manipulate or massage the treated area for at least 4 hours after the treatment. Initials:_____
Pregnancy &
Neurological
I understand that there are certain conditions where Botox® treatments are not recommended. These include: • Neurological disease, such as myasthenia gravis

Source: http://qaesthetics.co.uk/prac/documents/botox%20consent%201.pdf