Consent Form for Treatment

If you are considering Botulinum (often referred to as “Botox®”) injections, please read our terms and then fill in the below form or download the leaflet, here.

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1/3 Patient Personal Information
First Name
Last Name
Address 2
City / Town
Date of Birth
Next of Kin
Name of GP
2/3 Patient General Lifestyle Information
Do you smoke?
How many per week?
Are you an ex-smoker
When did you give up?
Do you drink alcohol
How many units per week?*

* A medium (175ml) glass is two units; a single spirit measure is one unit and a pint of beer is 2-3 units

Do you take regular exercise
What type of exercise?
Do you follow a special diet?
3/3 Medical History
Are you currently pregnant or breastfeeding?
Are you trying to conceive or underoing IVF treatment?

Do you suffer from or have you previously suffered from:

Pigment Disorders?
Increased scar formation?
Increased light sensitivity?
Herpes infections (shingles, chicken pox, cold sores, genital herpes sores)?
Skin cancer?
Keloid scarring? (lumpy overgrowth of scar tissue)
Acne, psoriasis or any other active skin condition or infection in the area(s) you wish to have treated?
Amyotropic lateral sclerosis (ALS)?
Myasthenia gravis, Eaton-Lambert syndrome, amyotrophic lateral sclerosis, multiple sclerosis?
Impaired ability to swallow or dysphagia?
Angina, cardiac infarction
High/low blood pressure?
Emotional or neurological disorders, e.g. seizures (epilepsy), oaralysis, depression, M.E. (Myalgic Encephalomyelitis)?
Bell's palsy or a stroke?
Thyroid problems?
HIV, hepatitis, rheumatoid arthritis or other auto immune diseases?
Nosebleeds, bruises (e.g. after a light touch) or coagulation disorders or bleeding disorders?
Do you or does anyone in your family suffer from a hereditary disease?
Do you have any allergies or hypersensitivities?e.g. hay fever, asthma, hypersensitivity?
To what?your full name

If you have an allergy card, please present it.

Have you ever been to hospital with a severe allergic reaction?
3/3 Medical History Cont...
Are you currently unergoing any desensitisation treatment?
Have you recently taken any medication or are you currently taking any medication??Pain killers, coagulation inhibitors, antibiotics, steroids, muscle relxants, (e.g. aspirin, warfarin, ibuprofen) or herbal preparations, viatmins and supplements.
Have you taken Roaccutane or Isotretinion (for acne) in the past 12 months?
Have you taken any recent immunisations?
Have you had any major surgery in the last six weeks?
Are you planning or currently undergoing dental treatment?
Have you previously undergone operations in your facial area?(e.g. laser, skin peel, facelift, IPL skin resurfacing, plastic surgery, injury, etc)
Do you have a phobia about blood or needles?
Are you prone to bruising?
Have you received local anaesthetic injections at your dental practice?
Have you recently been on a sunbed?
Any problems with dental local anaesthtics?
Have you received Botox type injections previously?
How long ago?
Did you experience any side effects or allergy?
Have you received filler injections?
How long ago?
If known, please specify the name of filler?
Do you have any permanent implants in your face?
Did you experience any side effects or allergy?
Which aspects of your face are you concerned about and what are your expectations about the outcome of the treatment?Which aspects of your face are you concerned about and what are your expectations about the outcome of the treatment
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Do you have any worries or concerns about treatments or anything else that you wish to tell us?Which aspects of your face are you concerned about and what are your expectations about the outcome of the treatment
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or call us on 01603 360360