Botulinum Toxin Consent Form

I confirm that I understand:

• Botulinum Toxin Type A uses the toxin produced by the bacteria responsible for botulism in food poisoning. However, the amount of toxin used is minimal and generally well tolerated in clinical trials. The toxin temporarily weakens the muscle responsible for developing facial expression lines caused by muscle activity. Static facial lines, e.g. those due to sun damage, will not usually respond to treatment with botulinum toxin, as they are not caused by muscle activity.

• Botulinum Toxin Type A is licensed for the temporary improvement of moderate to severe vertical lines between the eyebrows (glabellar lines) and is injected into the skin to reduce these lines. You are having these injections because the severity of your lines has had an important physiological impact on you.

• Treatment is not recommended if you are pregnant or breastfeeding.

• After treatment with Botox® you should start to see an improvement within 2 to 3 days, however the full effect can take up to 10 days. The benefits of treatment usually last between 3 and 6 months, but can vary depending on your individual response.

• The most common side effects of Botox® are headache and injection reactions e.g. redness, swelling, irritation, rash, itching, numbness, pain, discomfort, stinging, bruising and bleeding. Normally these reactions are mild to moderate, reversible and occur in the first week after treatment. There is also a small possibility of slight drooping of the eyelid, facial asymmetry or visual problems.

• Very rarely, botulinum toxin may result in muscle weakness away from the site of injection.

• If symptoms last for more than one week or you are concerned about any symptoms you should report them to your practitioner as soon as possible. Seek urgent medical help if you have difficulties breathing, swallowing, speaking or if your face swells up.

• Botox® may cause temporary blurred vision or muscle weakness. If affected, you should not drive or use machinery.

• Botox® contains a very small amount of albumin which comes from human blood. It is very unlikely that this could pass on an infection, but it cannot be entirely ruled out.

Botulinum Toxin Treatment Record

Botulinum Toxin Post Treatment Advice:

• Avoid lying down for one hour
• No constrictive head wear, (tight hats, hairbands etc.)
• No working out that day
• Do not massage the area after being injected
• No facials for one week
• No leaning on the area
• Avoid aspirin and any medications which may increase risk of bruising
• Gently remove make up that evening
• Sterile cover-up may be applied the following day
• Moving the muscles is fine – no evidence to suggest any excessive movement makes any positive difference to outcome

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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