If you have any concerns or questions no matter how big or small, please contact us immediately.
This form is not just a formality – it’s a record of you deciding to proceed with a procedure having considered the potential positive and negative outcomes and medical risks listed below, and the impact they may have on your wellbeing. Please initial next to the statements below to confirm you have read, understood and discussed as required with your clinician.
What is being injected?
Botulinum Toxin may be branded Azzalure, Botox or Bocouture is a purified protein produced by the bacterium clostridium botulinum. The product causes muscle relaxation and supresses sweating for 2- 6 months on average (with wide variation between individuals) by temporarily disrupting nerve activity to muscles and sweat glands. I understand that often treatments are given off label, as licensed use for prescribed treatments listed do not include most areas of available treatment.
What are the Side effects and Risks?
- Transient headache, swelling, bruising, bleeding, pain, twitching, itching, puffiness/oedema around the eyes or numbness or other changes in sensation• Allergy including anaphylaxis is possible but very rare• Asymmetry (unevenness) • Temporary drooping of facial features• Dry eyes• Double or blurred vision• The theoretical risk of complications unique to certain individuals are so far unknown.
Interactions: I have disclosed my medical and drug history to my clinician and am aware that many medications increase the risk of bruising and include but are not limited to Vitamin E, Aspirin, Motrin, Clopidogrel, Warfarin and others.
Contraindications: I can confirm – I do not suffer from a neuromuscular disorder, I am not taking muscle relaxants, do not have active infection and I am not pregnant or breastfeeding.
Limitations and alternatives: Occasionally the treatment wears off very quickly or does not work at all. Botulinum Toxin is best at treating dynamic facial lines; those caused by facial muscle activity. Lines present at rest may or may not improve and can be unpredictable.
Alternatives: I have considered alternatives to treatment, including doing nothing, topical creams, chemical peels, laser treatments, surgical denervation, forehead/brow lift, facelift, or hyaluronic acid treatments and elected that at this time Botulinum toxin is the best option for me.
Follow-up: I understand free adjustment injections are available for 4 weeks after my first treatment, but thereafter may incur a charge. I agree to follow aftercare advice.
Dissatisfaction: I understand that with all treatments the actual degree of improvement cannot be predicted or guaranteed. The outcome’s subjective nature means dissatisfaction is a possible outcome regardless of effectiveness of treatment. I understand that the effect of all treatments may gradually wear off and additional treatments may be necessary to maintain the desired effect.
Agreement: By signing this form, you agree that you have considered the side effects, risks and uncertainty of the outcome and decided the treatment is still in your best interests at this moment in your life. You have discussed all the details important to you with your clinician and shared all the information your clinician may need to plan a treatment. You agree that the balance of the benefits and risks to you overall favour the use botulinum toxin. You accept all the risks, complications and conditions of the procedure. You agree the practitioner has given you the opportunity to ask all remaining questions you may have about the treatment, and has answered them to the best of their ability. You agree you have been given time to consider the treatment detailed above.
I understand that the primary treatment of side effects and complications is included in the cost of the procedure and therefore no refunds are issued due to any of the above occurring. I understand photographs are taken and stored for 10 years as part of my clinical record.