BTX Consent Form

Patient Name

First

Last

Date of Birth

Aim of Treatment

The aim of this treatment is to significantly reduce the movement of the muscles causing expression lines, thus improving the appearance of such lines. This clinic uses Botox Cosmetic®, Dysport®, Xeomin®.

Common Side Effects Associated with the Injections Include:

Localised swelling, redness, tenderness
Bleeding at the sites of injection
Bruising
Numbness or itching of the area following injection.
Headache

The above usually resolve spontaneously within hours or days, but may persist for longer.

Asymmetry of expression – Perfect symmetry may not be achievable; that caused by the treatment, can often be corrected at your review appointment.

Common side effects associated with treatment with botulinum toxin to the upper face.

1%-10% risk

Eye lid ptosis (a drooping or heaviness of the eyelid, one or both), brow ptosis (heaviness and or lowering of the brow).
Facial pain

Uncommon Side effects

0.1-1% risk

Swelling/ puffiness around the eyes
Nausea
Anxiety
Dry mouth
Altered skin sensation, muscle twitching or spasm in the treated area
Eye pain, dry eyes, tearing, sensitivity to light, blurred vision, strabismus
Flu like symptoms
Itching or dry skin
Muscles not targeted may be effected
Infection

Also reported

Fever
Tinnitus, vertigo
Alopecia
Rash

*This list is not exhaustive, you may ask for a copy of the patient information leaflet in the pack, or check the Summary of Product Characteristics on-line.

Any adverse reactions usually occur within a few days of treatment. Botulinum toxin effects are not reversible. They are expected to be temporary in nature and usually resolve spontaneously within weeks. Rarely, symptoms may persist for several months.

The treatment of the brow, and any area other than frown or crows feet with botulinum toxin are not a licensed indications of Botox Cosmetic®, Dysport®, Xeomin®. The product manufacturer has no liability should a complication arise, when this medicine is used for indications that have not been licensed.

Expected Outcome

Successful treatment should prevent or significantly reduce the expressions causing the lines. Treatment may not cause the expression lines themselves to disappear completely. The expression may not be completely frozen, particularly if extreme effort is exerted to make any expression. Any decision to increase the dose, or repeat treatment, will be made at the discretion of the practitioner, informed by safety and best practice.

Please Confirm the Following:

I understand that though complications are uncommon, they do sometimes occur. It is possible that side effects not described may occur and indeed that a complication not previously reported may occur for the first time.
I understand if I suffer any adverse reactions that are not expected, or concern me, I must contact the clinic. An appointment will be made for me to be seen. The clinic cannot take responsibility for complications or results that have not been reported, assessed, documented and managed in a timely fashion.
I understand that whilst results desired and expected have been discussed, outcomes vary between individuals and cannot be guaranteed.
I confirm that the medical health history form has been completed truthfully and I am fully aware that withholding medical information, including history of previous treatment, may be detrimental to the safe and optimal outcome of any treatment administered. If there are any changes in my medical history, I must inform the practitioner.
I confirm that I have been provided with verbal and written information about this treatment which includes aftercare and follow up advice.
I agree to follow the aftercare advice and understand this reduces risk of adverse reactions and helps ensure optimum results.
I understand information about me will be treated as confidential and access to it restricted in accordance with the Data Protection Act, unless specific permissions given.
I consent to my medical records being shared with appropriate medical professionals
I understand photographs are taken as part of my medical record.

On occasion it is helpful to share visual images of our own treatment results. I consent to photographs being published for;

Educational and training purposes with medical professionals
Educational purposes with selected patients during consultation
Educational/promotional purposes in the clinics portfolio viewed by selected members of the public
Educational/promotional purposes on the clinic website
Educational purposes for selected public events
I understand that no fee is payable to me or any other person in respect of the material either now or at any time in the future.
I confirm that the purpose for which the material would be used has been explained to me in terms which I have understood.

I confirm that I have:

Taken the time to read: BTX Consent form, BTX Treatment Information and the Clinic Terms and Conditions

I accept the clinic terms and conditions. I am satisfied treatment with botulinum toxin has been explained comprehensively and that the possible risks and side effects associated with the treatment have been fully discussed and understood. I have taken sufficient time to process and consider the information provided and any questions I had have been answered to my satisfaction, before making a decision to proceed with the agreed treatment plan.

consent Birth Following:

Patient's Signature

Clear Signature

Practitioner

Dr Shabbir Kermali

Practitioner's Signature

Clear Signature

Today's Date

Aim of Treatment

Common Side Effects Associated with the Injections Include:

Expected Outcome

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