BOTOX CONSENT FORM BOTOX® CONSENT Form Name(Required) First Last Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address(Required) Street Address Address Line 2 City CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country 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. Consent(Required) 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. Consent 1(Required) I hereby give permission to my physician to take clinical photographs for diagnostic purposes and to enhance the medical record. I can confirm I have read and understood the Botox information and after care sheet. Consent 2(Required) 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. Consent 3(Required) 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. I confirm all questions have been answered implicitly to my satisfaction. Consent 4(Required) 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 Consent 5(Required) 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. which may result in the treatment. Signature Δ