Botox & Filler Consent Form

Medical history

Botox & Filler Consent Form
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityCountry

Postcode
Mobile phone*
Email
example@example.com
Please select any conditions that apply to you:

Rheumatic feverPacemakerEpilepsyDiabetesHeart problemsLiver or Kidney diseaseAsthmaHeart murmurJaundiceChest problemsHigh blood pressureHepatitisHayfeverBleeding disorderHeart surgeryBlackouts/ Fainting attacks/ GiddinessAny tablets for cancer or osteoporosisBad reaction to general anaestheticBad reaction to local anaestheticHospitalised for any operations/serious conditions in last 5 yearsTaken steroids in last 2 yearsDo you carry a warning cardAre you seeing a doctor at presentHad a joint replacedHave used needle delivered recreational drugsI have ALLERGIESI take pills/medications
I have these allergies:
I take these pills/medications:
If female, are you or do you think you may be pregant?
If you smoke, how many cigarettes do you smoke per day?
If you smoke, how many years have you smoked for?
How many units of alcohol do you drink per week?
Name and address of your doctor:*
Name and phone number of next of kin:*
I consent to sharing of information with my GP where necessary.
Please select any conditions that apply to you (contraindications for botox):

Pregnancy or breast-feedingActive infection in the treatment area (eg herpes simplex, pustular acne, cellulitis)Hypertrophic or Keloidal scarringBleeding abnormality (eg thrombocytopenia, anticoagulant use)Impaired healing (eg immunosuppression)Skin atrophy (eg chronic oral steroid use, ehlers danlos syndrome)Active dermatoses in the treatment area (eg 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 productsGross motor weakness in the treatment area (eg polio, Bell's palsy)Neuromuscular disorder inc. but not limited to amyotrophic lateral sclerosis, myasthenia gravis, lambert-eaton syndrome and myopathiesInability to contract muscles in the treatment area prior to treatmentPeriocular or ocular surgery within the last 6 monthsMedications that inhibit neuromuscular signalling and may potentiate botulinum toxin effects (eg aminoglycosides, penicillamine, quinine, calcium channel blockers)Uncontrolled systemic conditionOccupation requiring uncompromised facial expression (eg actors, singer)Unrealistic expectations or body dysmorphic disordersSevere needle phobia
Please select any conditions that apply to you (contraindications for fillers):

Pregnancy or breast-feedingInfection in the treatment area (e.g. Herpes simplex, acne)Hypertrophic or Keloidal scarringBleeding abnormality (eg thrombocytopenia, anticoagulant use)Roaccutane use within the last 6 monthsSkin atrophy (eg chronic steroid use, genetic syndromes such as ehlers-danlos syndrome)Impaired healing (eg due to immunosuppression)Dermatoses active in the treatment area (eg vitiligo, psoriasis, eczema)Uncontrolled systemic conditionPrevious anaphylactic reactionMultiple severe allergiesSensitivity or allergy to constituents of dermal filler productsBody dysmorphic disorderUnrealistic expectations
Dermal Fillers consent Form

Dermal fillers are used for the treatment of facial creases, wrinkles, folds, contour defects, depression 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
- Visible raised areas or bumpiness at/around the treated site
- Asymmetry, over correction or under correction.
- Unpredictable persistence of filler, either shorter or longer than anticipated
- Prolonged discolouration 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
- Tissue necrosis is extremely rare
- Blindness
Botox Consent Form

Injection of botulinum toxin causes weakness of targeted muscles, which can last approximately 2-4 months and over this time the effects will diminish. Injection of small amounts of botulinum toxin relaxes the treated 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.

Botulinum toxin-related
- Localised burning or stinging pain during injection
- Blepharoptosis (droopy eyelid)
- Eyebrow ptosis (droopy eyebrow)
- Ectropian 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 treatments 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 complications (can be any treatment):
- Pain
- Bruising
- Erythema
- Oedema
- Tenderness
- Headache
- Infection
- Numbness or paresthesia
- Anxiety
- Vasovagal episode and loss of consciousness
For most complications there are no corrective treatments and they spontaneously resolve as botulinum toxin effects diminish.

My signature below certifies that I have fully read this consent form and understand the written information provided to me regarding the proposed procedure. I have been adequately informed about the procedure including: the potential benefits, risks, limitations and alternative treatments and I have had all questions answered to my satisfaction. Clinically necessary top-up of botox within 4 weeks is included. Please note audiovisual recordings may be taken for records.
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Patient Instructions:

Botox and Dermal Fillers

Before treatment:
- Avoid aspirin, vitamin E, St. John's wort and other dietary supplements including ginkgo, evening primrose oil, garlic, feverfew and ginseng
  for 2 weeks.
- Avoid ibuprofen and alcohol for 2 days
- If possible, come to your appointment with a cleanly washed face.
General injection related complications:
- Pain
- Bruising
- Redness
- Swelling
- Tenderness
- Headache
- Infection
- Numbness
- Anxiety
Most will resolve in a few hours or a few days.

After treatment:
- Do not massage the treated areas on the day of treatment
- Avoid lying down for 4 hours immediately after treatment
- Avoid applying heat to the treated area on the day of treatment
- Avoid activities that cause facial flushing on the day of treatment, including consuming alcohol, hot tub or sauna use, exercising and
  tanning
- Gently apply a cool compress or wrapped ice pack to the treated areas for 15 minutes every few hours as needed to reduce discomfort,
  swelling, or bruising up to a few days after treatment. If bruising occurs, it typically resolves within 7-10 days
- After treatment, oral consumption and/or topical application of Arnica Montana may help to reduce bruising and swelling
- Botulinum toxin treatment effects take about 1-2 weeks to fully develop and last approximately 2.5-4 months
- Anti-wrinkle top up included within 4 weeks/28 days of treatment, book online at 656aesthetics.com
- If 2-4 weeks after treatment you feel that you need a correction or want to buy another syringe of filler, please book online at
  656aesthetics.com
- If you have any urgent problems or concerns following treatment please phone 07783867118, or if not urgent email: info@656aesthetics.com
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Medical history