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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.

I have been fully informed about the risks and benefits of treatment with Botox® and authorise the practitioner to treat me.


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