BOTOX CONSENT FORM 

     

     

    Date:

    Time:

     

    PERSONAL INFORMATION 

    Client first name: 

    Client surname: 

    Phone: 

    Date of Birth: 

    Gender: 

    Email address: 

    Address (optional): 

    Post code: 

    Patient ID: 

     

    Before undergoing any clinical procedure it is a legal requirement that you read and sign the following consent. This disclosure is not meant to scare or alarm you; it is simply an effort to ensure you have been fully informed, so you may give or withhold your consent to this procedure.

     

    I

    have been fully informed by my physician of the following conditions relating to the treatment of Botox:

      

    I have answered all of the questions regarding my health, skin and medical status correctly and to the best of my knowledge. I am aware that it is my responsibility to inform my physician if  there are any changes to medication or to my general health. I realise that withholding information may lead to complications.

    Please Initial:                                                                                                                                                                                         

     

    The cost of treatment has been advised and specific treatment parameters have been discussed and established. 

    Please Initial:                                                                                                                                                                                         

     

    I understand the aim of Botox treatment is to improve lines and winkles by breaking excessive habit of muscle movement in specific areas. I am aware it will not create perfection and eradication of dynamic lines on the face. 

    Please Initial:                                                                                                                                                                                         

     

    I understand that no guarantee has been made to me as to result or cure. Practice of medicine and surgery is not an exact science; therefore even reputable physicians cannot guarantee results. I am aware that it is possible that the result of treatment may not reach my 7full expectations or goals.

    Please Initial:                                                                                                                                                                                         
     

    I am aware that various conditions may require additional or different procedures than those originally planned.

    Please Initial:                                                                                                                                                                                         

     

    Treatment contra-indications have been discussed and I understand that I should not receive Botox treatment if any of the following applies:

     

    • Neuromuscular transmission disorders – Myasthenia Gravis, Eaton-Lambert syndrome
    • Known hypersensitivity to any ingredient in the formulation of Botox i.e. human albumin
    • Pregnant or lactating
    • Coagulation disorders or use of anticoagulant i.e. aspirin, warfarin
    • Use of amino glycoside antibiotics or streptomycin within 3 days of Botox treatment.
    • Unrealistic expectations
    • Lack of patient co-operation
    • Unrealistic fear of systemic botulism

    Please Initial:                                                                                                                                                                                         

     

    I realise that, as in all medical treatment, complications or a delay in recovery time is a possibility. If this occurs I understand that there may be a need for additional treatment, it could also result in an economic loss to me due to my inability to return to normal activities as soon as anticipated.

    Please Initial:                                                                                                                                                                                         
     

    I have discussed and I am aware of the possible risks and complications relating to Botox:

     

    • Potential swelling, bruising, bleeding, blood clots in veins and lungs (extremely rare) and allergic reactions.
    • Less than 10% of patients experience temporary discomfort from redness and mild swelling which resolves transiently within 48 hours.
    • On occasions Botox does not fully take, resulting in an uneven or incomplete response to treatment. In this case a minor touch up may be required in ensuring weeks.
    • Treatment of frown lines can cause minor temporary droopage of one eyelid. This occurs in approximately 1% of injections and usually last between 2-3 weeks, but is always reversible.
    • Botox will not improve static wrinkles due to skin thinning. Other types of skin management will be required.
    • Occasional numbness of the forehead may occur, lasting 2-3 weeks.
    • Bruising or transient headaches can occur, watery eyes and double vision have also been reported. This can last up to three months.
    • In peri-oral injections, the diffusion of Botox may transiently weaken the adjacent muscle tissue. This may result in patient’s inability to whistle or drink through a straw until the effects of the toxin wears off. Your smile may become asymmetrical.
    • When treating the chin area an asymmetry of mouth movement may occur.
    • No long term side effects are known.

     Please Initial:                                                                                                                                                                                         

     

    I hereby give permission to my physician to take clinical photographs for diagnostic purposes and to enhance the medical record. 

    Please Initial:                                                                                                                                                                                         

     

    I can confirm I have read and understood the Botox information and aftercare sheet. I agree to adhere to all of the advice and instructions given before, during and after the procedure. I will notify my physician of any problems following the procedure. 

    Please Initial:                                                                                                                                                                                         

     

    I certify that I have discussed all aspects of the treatment and have been given the opportunity to ask any questions or raise any concerns.

    Please Initial:                                                                                                                                                                                         


    I confirm all questions have been answered implicitly to my satisfaction.
    Please Initial:                                                                                                                                                                                         

     

    I hereby authorise my physician to administer the treatment and agree to hold him free and harmless from any claims, refunds or suits damages for any injury or complications whatsoever which may result in the treatment.

    Please Initial:                                                                                                                                                                                         
     

    I am aware that all cosmetic procedures are performed by Dr Mansoor Ahmed (London face Doctor). Dr Ahmed is extremely knowledgeable and highly qualified in these treatments and has over 15 years experience. Any queries regarding your treatment should be referred directly to Dr Ahmed who can be contacted via this clinic. Dr Ahmed is fully insured and registered with the GMC in addition Dr Ahmed is a member of both the British and European Associations of aesthetic medical doctors.

    Please Initial:                                                                                                                                                                                          

     

     

    Client Name:   

    Date:  Time:

    Client Signature:  >> Sign at document footer <<

     

      

    Select either YES/NO tick box as appropriate:  

    I hereby certify that I have discussed all of the above with the patient. I have offered to answer any questions regarding the procedure and believe the patient fully understands what I have explained and answered.

      

    Physician /Surgeon Name: 

    Date:  Time:

    Physician / Surgeon Signature:  >> Sign at document footer <<

     

     

     

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