top of page
KAA Logo

Consent to Treatment - Botulinum Toxin

Personal information

Multi-line address
Birthday
Day
Month
Year

This is an informed consent document that has been prepared to help inform you concerning Anti-wrinkle injections and the risks involved. It is important that you read this information carefully and completely.

Please complete each section, indicating that you have read the page and sign the consent at the bottom prior to your treatment.


Botox, dermal fillers and anti-wrinkle injections involve a series of small injections in order to weaken the chosen muscles. The weakening of the injected muscles begins to be apparent after 2-3 days with the peak effect being reached after 10-14 days. Results can last 3-6 months.


The procedure can be repeated after 3 months; however, injections given less than 3-month intervals may reduce the efficacy of the injections.

Risks

Every procedure involves a certain amount of risk, and it is important that you understand the risks involved. An individual's choice to undergo a procedure is based on the comparison of the risk to potential benefit.

Although the majority of patients do not experience these complications, you should discuss each of them with your practitioner to make sure you understand the risks, potential complications, and consequences of Anti-Wrinkle injections:


• Bleeding

• Bruising/Swelling

• Infection

• Unsatisfactory Outcome

• Temporary loss of function of nearby muscles.

Medical history

Do you have any medical conditions?
Yes
No
Are you pregnant / breastfeeding/ lactating or trying to get pregnant?
Yes
No
Do you have a neuromuscular disease (e.g. MS, ALS, motor neuropathy myasthenia gravis, or Lambert-Eaton syndrome)?
Yes
No
Do you have an autoimmune disease?
Yes
No
Do you have any skin conditions?
Yes
No
Do you have any active infection at the intended site of procedure?
Yes
No
Are you taking antibiotics or other prescription medications?
Yes
No
Concurrent use of aminoglycoside?
Yes
No
Do you use anticoagulants? E.g. Warfarin/Aspirin etc...
Yes
No
Do you have any known allergies or have ever had anaphylaxis?
Yes
No
Do you know the brand and product of Anti-Wrinkle injections you are having?
Yes
No
Is there any other Medical and/or Social History that we should know?
Yes
No
Have you had this or a similar treatment before? If so, did you experience any problems?
Yes
No

Consent

Do you have any concerns?
Yes
No
Do you understand the information you have been provided?
Yes
No
Do you feel sufficient information has been provided to you, to enable you to consent?
Yes
No
Has your consent been freely given?
Yes
No
I will retain this information throughout the course of my treatment and refer to it as required.
Yes
No

Signature

Date Signed
Day
Month
Year

Clinic

Treatment Date
Day
Month
Year
Date Signed
Day
Month
Year
bottom of page