Botulinum Toxin Consent Form

Botulinum Toxin Consent Form
Select todays date*

MonthDayYear
Date
Name

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What is Botulinum Toxin?

Botulinum Toxin is a bacterium that blocks the release of acetylcholine, which is responsible for the transmission of electrical impulses that stimulate nerve contraction. Or put more shortly, via this mechanism it stops muscle contracting. Medically it is directly injected into overactive muscles, and has been used since the eighties in treatment of strabismus (cross-eye) and blepharospasm (eyelid spasm). IT contains human albumin (a blood product) and isn’t vegan-friendly.
How does Botulinum Toxin work in the context of aesthetics?

Over activity of the facil muscles is what results in the development of lines or wrinkles on the face that we associate with aging. Injected Botulinum Toxin into the affected area acts to paralyse the muscles of that area and so decrease the wrinkling associated with this to give the face a more relaxes appearance. This results in the wrinkles becoming smoother or disappearing altogether.
How long does Botulinum Toxin take to work and how long does it work for?

The initial effects of the treatment will become visible in 48 to 72 hours, with maximum effect being reach at 1 to 2 weeks. It results in a overall decrease in wrinkles but not a decrease in the ability to express yourself facially. It generally lasts for 3 to 4 months before effects start to wear off and re-treatment is needed.
What are the potential adverse side effects?

It is generally a safe a effective treatment but as with most procedures side effects can occur. These include the risk of (but isn’t limited to):

·      Bruising or swelling at injection site
·      Slight nauseousness
·      Temporary drooping of the eyelid or eyebrow
·      Brief visual disturbances
·      Dryness of the eyes
·      Skin rash
·      Itching and allergic reaction
·      Headache
·      Tiredness
·      Pain in the arms or legs
Contraindications to Botulinum Toxin

·      Pregnancy and breast-feeding
·      Neuromuscular diseases such as Myasthenia gravis and Lambert-Eaton syndrome
·      Blood coagulation disorders or medically anti-coalgated patients
Drug Interactions

Some medications can alter the effects of Botulinum Toxin or interact with it so pleas make your practitioner aware of any medication you are taking. These include:

·      Aminogylcoside antibiotics such as gentamicin eyedrops
·      Aneasthetics
·      Muscle relaxants

CONSENT TO TREATMENT

I consent to being treated with Botulinum Toxin and having before and after photographs taken of this treatment. All photographs remain the property of Cosmic Clinics

I hereby certify that I have been fully informed of the nature and purpose of the procedure including expected outcome and possible complications.

I understand that there can be no guarantee or assurance as to the final result that may be obtained. Subjective dissatisfaction may be a possible outcome regardless of effectiveness of treatment. All people are individual and a refund will not be given after treatment.

I understand adjustments may be needed which may incur a further charge.

I have been given the opportunity to ask questions and hereby certify that I have read and full understood the contents of this consent form.
Signature

Clear
Practitioner signature

Clear
Should be Empty: