Consent for Treatment
I confirm that the botonics Specialist has given me sufficient information to enable me to understand the treatment in accordance with the approved indication. I have received information regarding the treatment’s contra-indications and potential undesirable effects. I have also been given the opportunity to ask all questions I have regarding the treatment and I have received additional explanation to my satisfaction. When completing the medical history, I have answered the questions fully and to the best of my ability.
If seeking Botox treatment, I have read the Botox Aftercare Instructions. I am aware that it is not licensed for cosmetic use in the United Kingdom. I have been specifically informed of the possible side effects that I may experience following an injection of Botox, which include bruising/swelling at the injection site, nausea/headache, occasional numbness, drooping of the eyebrow or upper eyelid, skin rash, allergic reactions and brief visual disturbances. I am happy that the use and indication for Botox has been explained to me and having answered a medical history to the best of my knowledge know of no reason that I should not be given Botox. My Specialist has informed me that the treatment will last for 3 – 4 months. I consent to being treated with Botox.
If seeking Dermal filler treatment, I have read the Dermal Fillers Aftercare Instructions. I confirm I have been informed that the treatment is injected into the dermis to correct wrinkles, volume loss, folds and lines of the face and skin or for lip augmentation. I understand that certain mild to moderate reactions usually disappearing in two weeks are common, including redness, swelling, pain, itching, bruising and tenderness at the implant location. There are risks to the underlying sensitive structures (e.g. nerves, vessels and eyes when treating wrinkles around eyes). Rare cases of infection, blindness, necrosis, abscess formation, granulomas and hypersensitivity have been reported. There are reactions that can occur several days to several months after treatment, that can last several months and be recurrent, including small lumps, irregularities, inflammatory reactions consisting of redness, swelling, prolonged induration, suppuration and greyish discoloration, scabbing and sloughing of tissue at the treatment site and surrounding tissue which can result in superficial scar formation. If seeking treatment with Radiesse, I understand that it is NOT possible do dissolve this filler after injection. Dermal fillers provide an aesthetic effect for an average of 3 – 12 months. This effect varies depending on the condition of the skin, area treated, amount of the product injected, injection technique and lifestyle factors such as sun exposure or smoking. In some cases, the effect may last for up to one year. A touch-up procedure between 6–12 weeks after the first injection helps to optimise the results and maximise the duration of the results. I consent to being treated with dermal filler.
If seeking Medical Needling treatment, I confirm I have been informed that the treatment may result in inflammatory reactions giving rise to, for example, bruising, redness, oedema and infection. This reaction may last for several days. Persistence of any inflammatory reaction for more than one week, or the development of any other side effects, must be reported to the Specialist as soon as possible. I consent to being treated with Medical Needling.
If seeking Skin Peel treatment, I confirm I have been informed that the treatment may exacerbate any existing pigmentation and may result in hyperpigmentation, hypopigmentation and scarring. I understand that shedding skin should never be picked or peeled, but rather cut away with scissors. tTe development of any side effects must be reported to the Specialist as soon as possible. I consent to being treated with Skin Peel.
If seeking Skin Care treatment, I agree to attend all scheduled reviews and to not use any over the counter products or prescription products self-prescribed via internet purchase or other means.
I confirm that I agree for my botonics specialist to take such photographs as required for diagnostic purposes and to enhance the medical records. I agree that these photographs will remain property of botonics. I agree/do not agree that botonics may use these discreetly for medical, scientific or other publications and presentations, marketing and website information with due respect to my client confidentiality.
I have been fully informed of the risks and possible consequences involved in the treatment being sought. I understand that no warranty or guarantee has been made to me as to result or cure. It is possible that the result might not live up to the expectations or goals established. In this connection I am aware that the practice of cosmetic dermatology is not an exact science and that therefore reputable specialists cannot guarantee results. I understand that there are NO REFUNDS. I hereby authorise the botonics Specialist to administer such treatment to me and agree to hold them free and harmless from any claims or suits for damage for any injury or complications whatever that may result from this treatment.