Patient Information
Treatment Details
Contraindications - Please confirm you do NOT have any of the following:
Pregnancy or breastfeeding
Neuromuscular disorders (e.g., myasthenia gravis, Lambert-Eaton syndrome)
Allergy to botulinum toxin or any ingredients in the product
Infection or inflammation at the proposed injection sites
Current use of aminoglycoside antibiotics or blood-thinning medications
Previous adverse reaction to botulinum toxin treatments
Risks and Potential Complications
I understand that the following risks and complications may occur:
- Common: Bruising, swelling, redness at injection sites
- Common: Headache (usually resolves within 24-48 hours)
- Uncommon: Temporary eyelid or brow drooping (ptosis)
- Uncommon: Asymmetry requiring adjustment
- Uncommon: Flu-like symptoms
- Rare: Difficulty swallowing or breathing (seek immediate medical attention)
- Rare: Allergic reaction
- Rare: Spread of toxin to other areas
Patient Acknowledgements
By signing below, I confirm that:
I have been given adequate time to consider this treatment and ask questions
I have disclosed all relevant medical history, medications, and previous treatments
I understand the procedure, expected results, and limitations
I understand that results are temporary (typically 3-4 months) and repeat treatments are needed
I understand the risks and potential complications as explained above
I have received and understood the aftercare instructions
I understand that no guarantee of results has been made
I consent to before and after photographs for my medical records
I am over 18 years of age
Data Protection Notice (GDPR): Your personal and medical information will be stored securely in accordance with UK GDPR and the Data Protection Act 2018. Your data will only be used for the purposes of your treatment and care. You have the right to access, rectify, or request deletion of your data. For full details, please see our Privacy Policy.
I have read and understood this consent form and agree to proceed with treatment.
Practitioner Name (Print)