Botulinum Toxin Consultation Form

Your Decision – What’s best for you?

Client Name: *

Date: *

Date of Birth: *

Email: *

Medical History

Please complete the following medical questionnaire:

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 give details:

Are you currently receiving any medical treatment? *

Please give details:

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 give details:

Do you suffer from acute rheumatoid arthritis or recurrent sore throat? *

Please give details:

Do you have any allergies/intolerances? *

Particularly Hyaluronic Acid

Please give details:

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 suppresses 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: *

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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