BOTOX CONSENT FORM

BOTOX® CONSENT Form

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I, have been fully informed by my physician of the following conditions relating to the treatment of Botox. I have answered all 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. The cost of treatment has been advised and specific treatment parameters have been discussed and established. 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. 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 full expectations or goals. I am aware that various conditions may require additional or different procedures than those originally planned. 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 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. 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.
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