Botulinum Treatment Consent Form

Name *

First

Last

(IC) Identification Number / FIN

Todays Date

Undertaking

Botulinum is a very popular non-surgical cosmetic treatment only to be administered by a registered doctor. It is used to reduce fine lines and wrinkles in the area of the glabella muscles by paralyzing the muscles temporarily; or in the forehead; or crows’ feet around the lateral area of the eyes.
I understand that Botulinum toxin A will be injected to cause specific muscles to halt their function (be paralyzed), thereby improving the appearance of the wrinkles. I also 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.
I understand that due to the nature of injection, there might be an uneven appearance of the face with some muscles more affected by Botulinum than others. In most cases, this uneven appearance can be corrected by injecting Botulinum in the same or nearby muscles. However, in some cases, this uneven appearance can persist for several weeks or months.
The number of units injected is an estimate of the amount of Botulinum require to paralyze the muscles. I understand that there is no guarantee of results.

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

I understand that there is a risk of swelling; rash; headache; local numbness; pain at injection site; bruising; respiratory and allergic reaction.
Infections can occur which in most cases are easily treatable, but in rare cases, a permanent scarring in the area can occur.
You might experience light swollen pinkish bumps where the injection went in, for a couple hours to several days.
You might experience headaches following treatment with Botulinum. The headache can persist for several days or weeks.
Local numbness; rash; pain at site of injection;
Respiratory problems such as bronchitis or sinusitis; nausea; dizziness and tightness when breathing.
Bruising is possible when injected with a needle into the skin. Bruising can last for hours; days; weeks; months and in rare cases the damage could be permanent.
While local weakness of the injected muscles is representative of the expected pharmacological action of Botulinum, weakness of adjacent muscles may occur as a result of the spread of the toxin.

What you can expect from this treatment:

You will go through a general cleansing of your face (area to be treated)
Typically, a Botulinum treatment of 10 to 25 units will take about 10 -15 mins
You might be asked to make a certain facial expression (eg a frown, to raise your eyebrows). During the treatment, you may occasionally feel a pricking sensation, but otherwise the level of discomfort will be minimal.
Immediately after treatment, you will need to stay upright for at least 30 mins to allow the solution to properly settle in your muscles.
I am aware to report any unusual side effects that might occur after the course of the treatment. (common side effects with include: feeling nausea or blurred vision; headaches; respiratory infection; flu; eyelid droop etc)
Do expect some redness and bruising. Do not scrub or rub too hard on the treated area, and do avoid strenuous exercise for at least 2-3 days.
You will start feeling the effect approximately 2 – 7 days after the first treatment.
I am aware that I can take up additional treatments to reach my desired outcome.
I have been briefed on post treatment care. (Eg. To refrain from smoking; sun-tanning; alcohol; hot steam bath; sauna for 1week etc)

Are you currently being administered with NSAID; Aggregation Inhibitor; Anticoagulant; Immunosuppressant etc

Yes
No

Impaired Skin Sensation; Open and/ or Infected Wounds

Yes
No

Pregnancy or Lactation

Yes
No

Allergy to protein in Cow/s milk

Yes
No

Recent Surgery or Scars on the Area to be Treated

Yes
No

I’m not hypersensitive to Botulinum Toxin A

Yes
No

Thick Wrinkles and/ or Oily Skin

Yes
No

With my consent/ signature below:

I hereby authorize the doctor to perform Botulinum Toxin A to me.
I also consent to being photographed and for digital images to being taken during the course of my treatments. The physician/technician will do their best to blur identifying details in the photographs in order to keep my identity discreet
I certify that I have read all the above informed consent and fully understand it. I have been given ample opportunity for discussion and all my questions have been answered to my satisfaction, and thereby consent to the terms of the agreement.

ACKNOWLEDGMENT

BY MY SUBMISSION BELOW, I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS INFORMED CONSENT FOR THE USE OF BOTULINUM, AND THAT I HAVE HAD ALL MY QUESTIONS ANSWERED TO MY SATISFACTION BY MY HEALTHCARE TEAM.

Patient Consent Form (Botulinum Toxin A)