Botulinum Toxin Consultation, Medical History and Consent Form

Client Name: *

Date: *

Date of Birth: *

Email: *

Address: *

Postcode: *

Home Phone:

Mobile: *

May we contact you by text or email? *

Yes No

Medical History

Please complete the following medical questionnaire:

Are you currently taking any medication or supplements? *

Please specify:

Are you pregnant, planning a pregnancy or breast feeding? *

Pregnant Planning a pregnancy Breastfeeding N/A

Have you a history of severe allergy / anaphylaxis? *

Please specify:

Do you have any other allergies/intolerances? *

Please specify:

Are you currently receiving any medical treatment? *

Please specify:

Have you previously received any aesthetic treatment (e.g. laser, peels, dermabrasion etc.)? *

Which treatment did you receive, what areas were treated and when?

Have you had any dermal filler treatment or Botulinum Toxin? *

Which treatment did you receive, what areas were treated and when?

Have you ever suffered from any auto-immune disease affecting the immune system? *

(e.g. rheumatoid arthritis, psoriatic arthritis, ulcerative colitis, Crohn's disease, lupus erthematosus, polyarteritis nodosa / scleroderma / polymyositis, Sjogren's syndrome, Grave's disease, ankylosing spondylitis, etc).

Please give details:

Do you have any cutaneous (skin) infection or inflammatory problems at the injection site (e.g. herpes, acne etc)? *

Please give details:

Are you susceptible to hypertrophic scarring? *

Please specify:

ANY ADDITIONAL NOTES/COMMENTS:

Please use this box for any additional notes/comments on your medical history/conditions/medications

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.

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.

Please tick the boxes you have read, understood and discussed as required with your clinician.

What are the Side effects and Risks?

_

After Care tips:

For at least 4 hours (after treatment)
- Keep upright, do not bend excessively

For 12 hours (after treatment)
- Avoid extreme facial expressions
- Avoid excessive alcohol consumption
- Avoid wearing makeup

For 2 days (after treatment)
- Do not rub or massage the treated area, this may cause the injected solution to spread to nearby muscles
- After washing, pat skin dry very gently with a soft towel

For 2 Weeks (after treatment)
- Avoid exposure to strong sunlight, very cold temperatures and saunas
- Do not have any beauty treatments on your face e.g. facials, facial massage

Client Signature: *

Tap or click on the signature above to sign

Clinician: I confirm I have summarised the relevant consent information verbally and checked understanding.

Clinician Signature: *

Tap or click on the signature above to sign

Data Protection and Privacy

We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.

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