Botulinum Toxin Consultation and Medical History Form

Your Decision – What’s best for you?


Medical History

Please complete the following medical questionnaire:

(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 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?

Client signature:



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Data Protection and Privacy

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