ANTI-WRINKLE (BOTULINUM TOXIN) TREATMENT
CONSENT FORM
Patient Information
Full Name:
First Name
Last Name
Date of Birth:
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Day
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Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Phone Number:
Format: 00000000000.
Email:
example@example.com
Treatment Details
Treatment Area(s):
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Date of Treatment:
Medical History
Please tick if you have any of the following:
Allergies (please specify):
Other
Pregnancy or breastfeeding
Neuromuscular disorders (e.g. myasthenia gravis)
Current infection at treatment site
Previous adverse reaction to botulinum toxin
Use of antibiotics or muscle relaxants
Bleeding disorders or use of blood-thinning medication
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Any other medical conditions:
Other
Treatment Information
Anti-wrinkle injections use botulinum toxin to temporarily relax facial muscles, reducing the appearance of fine lines and wrinkles. Common areas include the forehead, frown lines, and crow's feet. Results typically begin to appear within 3-14 days and last approximately 3-4 months, though this varies between individuals.
Consent
I confirm that:
I have read and understood this consent form
I have had the opportunity to ask questions
I understand the risks, benefits, and alternatives
I consent to the anti-wrinkle treatment being performed
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I understand that results are temporary and not guaranteed, and
that further treatments may be required.
Photography Consent (Optional)
I consent to photographs being taken for medical records
I consent to use of images for marketing/education
Patient Signature:
Date:
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Day
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Month
Year
2 digit day, 2 digit month, 4 digit year
Date
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