Botox Consent Form

BOTOX/ANTI-WRINKLE INJECTIONS AFTERCARE
The following aftercare advice is essential to help reduce the risk of treatment
complications, to improve your comfort/healing and to help achieve the best possible
results from treatment.
After treatment the skin may be red, swollen and sometimes bruised at the injection
sites. These after-effects will resolve naturally, usually within a few days however it may
take up to 2 weeks for more extensive bruising to resolve. Occasionally you may
experience a headache after treatment which may last 1-2 days. Usually this is
controlled by taking simple over the counter pain killers such as paracetamol.
Please follow the aftercare advice for Botox/Anti-Wrinkle injections.

• Avoid applying makeup to the treated area for 24 hours, this can help reduce the
risk of infection.
• Avoid any extremes of temperature for the next 24 hours, for example have a
tepid shower or bath rather than hot.
• Avoid exercising or strenuous activity for the first 24 hours post-treatment.

• Do not go swimming or use saunas or steam rooms for at least 24 hours post-
treatment.

• No excessive alcohol on the day of the treatment.
• Do not lie flat or face down for at least 4 hours after treatment. Remain upright for
4 hours after treatment, this can help to reduce product migration.
• Avoid touching or rubbing the treated after for at least 24 hours after treatment,
doing so may affect treatment results.
• Avoid any further cosmetic procedures to the treated area for 2 weeks following
treatment, including permanent makeup and skin treatments.
• You must seek medical attention and contact your practitioner if you experience
any signs or symptoms of infection after treatment. Infection can present as hot,
red shiny skin, there may be pus formation and you may have a fever or feel
generally unwell.

• You must seek emergency medical attention if you experience any severe allergy
symptoms after treatment. Symptoms may include rash, facial swelling and
breathing difficulties.
• Contact your practitioner as soon as possible if you notice any other unwanted
side effects.
• Allow 2 weeks before assessing results of treatment. If after 2 weeks there is any
persistent unevenness or the product as not fully taken contact your practitioner
for review.
It is essential that you have read all of the information available. Once you have read and
understood all of the below, please sign the declaration at the bottom of this form. Please
do let your practitioner know if you have any questions or if you do not understand any of
the aftercare instructions provided below.
I confirm that I have read and understood all the information on this Form and that I have
been given the opportunity to ask any questions that have come to mind throughout.

I confirm I have been informed that:

BOTOX is indicated for the temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at maximum frown (glabellar lines); moderate to severe lateral canthal lines (crow’s feet lines) seen at maximum smile; moderate to severe crow’s feet lines seen at maximum smile and glabellar lines seen at maximum frown when treated simultaneously in adults, when the severity of these lines has an important psychological impact for the patient.

Like all medicines, BOTOX can have side effects, although not everybody gets them. In general, side effects occur within the first few days following injection. They usually last only for a short time, but they may last for several months and in rare cases, longer. These adverse reactions may be related to treatment, injection technique or both.

Diffusion of botulinum toxin into nearby muscles is possible when high doses are injected, particularly in the neck area.

As expected for any injection procedure, pain/burning/stinging, swelling and/or bruising may be associated with the injection. Speak to your doctor if you are worried about this.

Adverse reactions possibly related to the spread of toxin distant from the site of administration have been reported very rarely with botulinum toxin (e.g. muscle weakness, constipation, difficulty in swallowing, food or liquid accidentally going into the lungs which in some cases may lead to pneumonia). Injection of BOTOX is not recommended in patients with a history of dysphagia (difficulty to swallow) and impaired swallowing.

The chance of having side effects is described by the following categories:

please tell your doctor or pharmacist.

BOTOX should only be administered by medically qualified physicians with appropriate qualifications and expertise in this treatment and having the required equipment.

Too frequent or excessive dosing of BOTOX may increase the risk of antibodies in the blood which may lead to failure of treatment with botulinum toxin when used for this and other conditions.

The aesthetic effects of BOTOX last for an average of 3-4 months but will vary depending on the condition of the skin, area treated, amount of product injected, injection technique and lifestyle factors such as sun exposure and smoking.

After treatment, please avoid extreme facial expressions, alcohol consumption and applying make-up for 12 hours. Please avoid extreme sun exposure, UV light, freezing temperatures and saunas for 2 weeks after treatment.

I confirm that my treating practitioner has:

Provided me with sufficient information about the treatment detailed in the form in order to make an informed decision

Given me the opportunity to ask all remaining questions I may have about the treatment, and has answered them to best of their ability

Given me the time to consider the treatment

Received the relevant medical history information from me to the best of my knowledge

I therefore consent to receiving the described treatment by my treating practitioner.