Consent and Consultation

Form for Patients being treated

by Botulinum Toxin Type A

YesNo
YesNo YesNo YesNo YesNo
YesNo YesNo
YesNo YesNo YesNo
Have you ever Suffered from any of the following ?

Heart Disease
YesNo
Diabates
YesNo
Convuolsions
YesNo
Thyroid Problems
YesNo
Stomach Ulcer
YesNo
Venereal Disease
YesNo
Auto Immune Disease
YesNo
Depressions
YesNo
Skin Disease
YesNo
Facial Palsy
YesNo
Arthritis
YesNo
High/ low blood pressure
YesNo
Hepatitis
YesNo
Phelebitis
YesNo
Asthama/Bronchitis
YesNo
Facial cold sores
YesNo
Cataract
YesNo
Hypoglycaemia
YesNo
Are you pregnant/Breast feeding?
YesNo
Have a history of severe allergy/anaphyaxis
YesNo
Have a history of severe allergy/anaphyaxis to Botolinum toxin Type A or its excipents
YesNo
Do you suffer from Mysanthenia Gravis or Eaton Lambert Syndrome
YesNo


  • If you have any problems or questions discuss them with your practitioner.
  • If the answer to any of the questions above is yes, the practitioner will ask further questions.Treatment may be cancelled if its not in your interest to proceed further.

    Advised Content

    I confirm that i have been informed the following:

    Read Advise

    I confirm that i have been informed the following: Botolinum Toxin Type A is indicated for the temporary improvement in the appearence of moderate to severe vertical lines between the eyebrows seen at maximum frown(glabellar lines);moderate to severe canthal lines seen at maximum smile;moderate to severe crow's feet lines seen at maximum smile and glabellar lines seen at maximum frown when treated in adults, when the severity of these lines has an important pyschological impact for the patient. Like all medicines Botulinum Toxin Type A can have side effects although not everybody gets them. In general, side effects occur within the first few days following infection. They usually last only for a short time, but they may last for several months an in rare cases, longer. These adverse reactions may be related to treatment or technique or both. Diffusion of botulinum into nearby muscles is possible when high doses are injected, particularly in the neck area.

    As expected for any injection procedure, pain/ burning/ stinging, swelling and/or bruising may be associated with the injection, Speak to your doctor if you are worried about this. Adverse reactions possibly related to the spread of toxin distant from the site of administration have been reported very rarely with botlinum toxin eg. muscle weakness, constipation, difficulty in swallowing, food or liquid accidently going into the lungs which in some cases may lead to pneunomia). Injection of 86% is not recommended in patients with a history of dysphagia and impaired swallowing.

    The Chance of having a side effect is described by the following categories:
    Common:More than 1 out of 100 persons and less than 1 out of 10 persons.
    Uncommon:More than 1 out of 1000 persons and less than 1 out of 100 persons.

    Injections in the forehead for vertical lines
    Common side effects are- Headaches, dropping eye lid, skin redness, localised muscle weakness, lace pain.
    Uncommon side effects are- infection, anxiety, numbness, diziness, inflammation of the eyelid, eye pain, visual disturbance, nausea, dry mouth, skin tightness, swelling, sensitivity to light, itching, dry skin, muscle twitching, flu syndrome, lack of strenght, fever.

    Injections in the fan-shaped lines from the corner of the eyes
    Common side effects are- Swelling of the eyelids, injection site bleeding and/or, bruising.
    Uncommon side effects are- Injection site pain and/or tingling or numbness

    Injections in the fan-shaped lines from the corner of the eyes, when treated at the same time as the injections in the forehead for the vertical lines.
    Common side effects are: Injection site bruising.
    Uncommon side effects are: Injection site bleeding and/or pain.

    The following additional side effects have been reported for Botulinum Toxin Type A since it has been marketed: allergic reactions, which can be serious welling of the face and airways, difficulty in breathing, loss of nerve supply to/shrinkage of infected muscle, respiratory depression and/or respiratory failure, aspiration pneumonia(lung inflammation caused by accidently breathing in food, drink, saliava or vomit), chronic disease affecting the muscles(myasthenia gravis), blurred vision, difficulty in seeing clearly, slurred speech,strabisums(squint), numbness, tingling and pain in hands and feet, fainting, pain/numbness/or weakness of the face muscles, difficulty moving the arm and shoulder, decreased skin sensation, muscle pain, abdominal pain, diarrhoea, vomiting, loss of appetite, dry mouth, feeling sick, fever, different type of red blotchy skin rashes, feeling generally unwell, speech problems, itching, excessive, sweating, hair loss, loss of eyebrows, decreased hearing, noises in the ear, feeling of dizziness or "spinning"

    Allergic reactions, difficulties to swallow, speak or breathe, have been reported rarely when botolinum toxin type A has been used for other users. Visit your doctor immediately if such signs develop after Botulinum Toxin Type A treatment. If any of the side effects get serious, or if you notice any side effects not listed in the form, please tell your doctor or pharmicist.

    Botulinum Toxin Type A should only be administered by medically qualified physicians with appropriate qualifications and expertise in this treatment and having required equipment.

    Too frequent or excessive dosing of Botolinum Toxin Type A may increase the risk of anitbodies in the blood which may lead to failure of treatment with botolinum toxin used for this and other conditions.

    The asthetics effects of Botolinum Toxin Type A last for an average of 3-4 months but will vary deponding on the condition of skin, area tested amount of product injected, injection technique and lifestyle factors such as sun exposure and smoking.

    After treatment, please avoid extreme faical expressionsm alcohol consumption and applying makeup for 12 hours. Please Avoid extreme sun exposure, UV light, freezing tempratures and saunas for 2 weeks.
    Please ask your treating practitioner for a copy of the botolinum Toxin Type A Package insert

    I confirm that my treating practitioner has:
    • Provided me with sufficient information about the treatment detailed overleaf in order to make an informed decision.
    • Given me the Oppurtunity to ask all the remaining questions that i may have about the treatment and has answered them to the best of their ability.
    • Given me the time to consider the treatment detailed overleaf.
    • Recieved the relevant medical history information from me to the best of my knowledge.
    Signature:

    Date: