BOTOX CONSULTATION FORM Web Site Your Details First Name * Last Name * Email Address * Phone Number * Address * Post Code * Contraindications - Botulinum toxin Please tick all that apply Select all that apply Pregnancy or Breastfeeding Active Infection in Treatment Area (e.g. herpes simplex, pustular acne, cellulitis) Hypertrophic or Keloidal scarring Bleeding abnormality (e.g. thrombocytopenia, anticoagulant use) Impaired Healing (e.g. immunosuppression) Skin atrophy (e.g. chronic oral steroid use, ehlers danlos syndrome) Active dermatoses in the treatment area (e.g. psoriasis, eczema) Sensitivity or allergy to constituents of botulinum toxin (inc. botulinum toxin serotype a, human albumin, lactose or sodium succinate) Milk Allergy with abobotulinumtoxinA products Gross Motor Weakness in the treatment area (e.g. polio, Bell's palsy, Guillain-Barre syndrome autoimmunie disorder) Neuromuscular disorder inc. but not limited to amyotrophic lateral sclerosis, myasthenia gravis, lambert-eaton syndrome and myopathies Inability to contract muscles in the treatment area prior to treatment Periocular or ocular surgery within the last 6 months Medications that inhibit neuromuscular signalling and may potentiate botulinum toxin effects (eg aminoglycosides, penicillamine, quinine, calcium channel blockers) Uncontrolled systemic condition Occupation requiring uncompromising facial expression (eg actors, singer) Unrealistic expectations or body dysmorphic disorders Severe needle phobia NONE OF THE ABOVE More information Contraindications - Dermal Fillers Please tick all that apply Select all that apply Pregnancy or Breastfeeding Active Infection in Treatment Area (e.g. herpes simplex, pustular acne, cellulitis) Hypertrophic or Keloidal scarring Bleeding abnormality (e.g. thrombocytopenia, anticoagulant use) Roaccutan use within the last 6 months Skin atrophy (e.g. chronic oral steroid use, ehlers danlos syndrome) Active dermatoses in the treatment area (e.g. psoriasis, eczema) Impaired Healing (e.g. due to immunosuppression) Uncontrolled systematic condition Previous anaphylactic reaction Multiple Severe Allergies Sensitivity or allergy to constituents of dermal filler products Unrealistic expectations or body dysmorphic disorders NONE OF THE ABOVE More information Dermal Fillers - Consent Form Dermal fillers are used for the treatment of facial creases, wrinkles, folds contour defects, depressions scars, facial lipoatrophy (loss of fat) and enhancement purposes. These treatments involve multiple injections of filler into or below the skin to fill wrinkles and restore volume. The effects of dermal fillers are temporary and no guarantees can be made regarding how long correction will last in a specific patient. Alternatives to temporary fillers include, but are not limited to: permanent dermal fillers, laser resurfacing and skin tightening, surgical facelift or no treatment at all. Possible risks, side-effects, and complications with dermal fillers include but are not limited to: • Bruising, redness and swelling • Visibly raised areas or bumpiness at/around the treated sites • Asymmetry, overcorrection or under correction • Unpredictable persistence of filler, either shorter or longer than anticipated • Prolonged discoloration of the skin such as brown, greyish, bluish or reddish colouration • Filler material may be extruded from the skin in rare cases • Prolonged or severe swelling • Infection • Rarely granulomas or firm nodules may form • Benign tumour formation (keratoacanthomas) • Allergic reaction with itchiness, redness and in extremely rare cases generalised allergic response such as a whole-body swelling, respiratory problems and shock • Scarring is extremely rare • Skin breakdown or ulceration • Blindness Botox - Consent Form Injection of botulinum toxin causes weakness of targeted muscles, which can last approximately 2-4 mmonths and over this time the effects will diminish. Injection of small amounts of botulinum toxin relaces the treade muscles and can reduce facial wrinkles such as frown lines. It is injected with a small needle into the targeted muscles. Effects are typically seen in a few days and can take 1-2 weeks to fully develop. Possible risks, side-effects, and complications with botulinum toxin include but are not limited to: Botulinum toxin-related • Localised burning or stinging pain during injection • Blepharoptosis (droopy eyelid) • Eyebrow ptosis (droopy eyebrow) • Ectropion of the lower eyelid (eyelid margin eversion) • Lagophthalmus (incomplete eyelid closure) • Xerophthalmia (dry eyes) • Epiphora (excess tearing) • Diplopia (double vision) • Impaired Blink Reflex • Photophobia (light sensitivity) • Globe trauma • Infraorbital festooning (worsening of eyebags) • Lip ptosis with resultant smile asymmetry • Oral incompetence with resultant drooling and impaired speaking, eating or drinking • Cheek flaccidity • Dysarthria (difficulty articulating) • Dysphagia (difficulty swallowing) • Hoarseness • Neck weakness • Facial asymmetry, alteration or poor aesthetic result • Inadequate reduction of wrinkles or lack of intended effect in the treatment area • Worsening wrinkles in areas adjacent to the treatment area • Weakening muscles adjacent to the treatment area • Autoantibodies against botulinum toxin. Autoantibodies may be present or develop after injection, rendering treatment ineffective (1-2% of patients treated for cosmetic indications) • Extremely rare, immediate hypersensitivity reaction with signs of urticaria, oedema and a remote possibility of anaphylaxis General Injection-related • Pain • Bruising • Erythema • Oedema • Tenderness • Headache • Infection • Numbness or paresthesia • Anxiety • Vasovagal episdoe and loss of consciousness For most complications there are no corrective treatment and the spontaneously resolve as botulinum toxin effect diminish. Clinically necessary top-up of botox within 3 weeks in included. By submitting this form, I certify that I have fully read this consent form and understand the written information provided to me regarding the proposed procedure. I ahve been adequately informed about the procedure including: the potential benefis, risks, limitations and alternative treatments and I have had all questions answered to my satisfaction.
