Botulinum Toxin Consultation and Medical History Form
Your Decision – What’s best for you?
Please complete the following medical questionnaire:
Please inform your Clinician about any other medical conditions.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. I understand that often treatments are given off label, as licensed use for prescribed treatments listed do not include most areas of available treatment.Please tick the boxes you have read, understood and discussed as required with your clinician.
What are the Side effects and Risks?
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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.