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Consent Forms

Anti-wrinkle Injections - Consent Form

Birthday

 Marketing

We would like to contact you with special offers, related products and relevant services. If you consent for this purpose, tick you preference:

Tick your preference

Photographs taken shall be part of the medical record and used for documentation of response to treatment. With explicit permission these photographs may also be used for educational purposes or for client information.

Multi choice

As part of the marketing activity (digital and/or print) we would like to use anonymously before & after photos of your treatment for use to promote this treatment.

Multi choice

Introduction to Anti-wrinkle injections

I confirm I have seen aesthetic practitioner for a medical health check prior to today's treatment.


Multi choice

  1. Botulinum A Toxin injection take approx. 2 weeks to take full effect- they are NOT IMMEDIATE

  2. Injection of Botulinum A Toxins into the small muscles between the brows causes those specific muscles to halt their function (be paralysed), thereby improving the appearance of the wrinkles

  3. This paralysis is temporary and re-injection is necessary within three to four monthsI understand that will be injected with Botulinum A Toxin in the area of one, or more from the list below to paralyse these muscles temporarily:

  • Glabella, Corrugator Supercilii and Procerus muscles- Frown lines

  • Frontalis Muscle- -Forehead

  • Lateral Orbital Lines: Orbicularis Oculi and Procerus Muscles- Crow's Feet side of your eyes

  • Bunny Lines (Transverse nasal)- around your nose

  • Perioral Lines (Smoker" 's Lines): Orbicularis Oris Muscle

  • Marionette Lines: Depressor Anguli Oris and/or Trangularis Muscles

  • Mentalis Dysfunction (Chin "Dents"): Mentalis Muscle

  • Vertical Platysma Bands: Platysma Muscle

  • Hyperhidrosis (excessive sweating): blocking the release of acetylcholine. (Acetylcholine is the body's chemical which stimulates the sweat glands)

  • Armpits: Axillary


l understand the goal is to decrease the wrinkles in the treated areas, or reduce sweating in the relevant area listed above. Please sign to acknowledge you understand and consent to continuing with the procedure.

The possible side effects of Botulinum A Toxin include but are not limited to:

RISKS: A risk of swelling, rash, headache, local numbness, pain at the injection site, bruising, respiratory problems, and allergic reaction.


INFECTION: Infections can occur which in most cases are easily treatable bit in rare cases a permanent scarring in the area can occur.

Most people have slightly swollen pinkish bumps where the injections went in, for a couple of hours or even several days. Although many people with chronic headaches or migraines often get relief from Botulinum A Toxin, a small percent of patients get headaches following treatment with Botulinum A Toxin, for the first day. In a very small percentage of patients these headaches can persist for several days or weeks. Local numbness, rash, pain at the injection site, flu like symptoms with mild fever, back pain. Respiratory problems such as bronchitis or sinusitis, nausea, dizziness, and tightness or irritation of the skin. Bruising is possible anytime you inject a needle into the skin. This bruising can last for several hours, days, weeks, months and in rare cases the effect of bruising could be permanent.


While local weakness of the injected muscles is representative of the expected pharmacological action Botulinum A Toxin, weakness of adjacent muscles may occur as a result of the spread of the toxin.


TREATMENTS: More than one injection may be needed to achieve a satisfactory result. Another risk when injecting Botulinum A Toxin around the eyes included corneal exposure because people may not be able to blink the eyelids as often as they should to protect the eye. This inability to protect the eye has been associated with damage to the eye as impaired vision, or double vision, which is usually temporary. This reduced blinking has been associated with corneal ulcerations. There are medications that can help lift the eyelid, however, if the drooping is too great the eye drops are not that effective. These side effects can last for several weeks or longer. This occurs in 2-5 percent of clients.

As Botulinum A Toxin injections are not an exact science, there might be an uneven appearance of the face with some muscles more affected by the Botulinum A Toxin than others. In most cases this uneven appearance can be corrected by injecting Botulinum A Toxin in the same or nearby muscles. However, in some cases this uneven appearance can persist for several weeks or months.

This list is not meant to be inclusive of all possible risks associated with Botulinum A Toxin as there are both known and unknown side effects associated with any medication or procedure.

 

  • Botulinum A Toxin should not be administered to a pregnant or breastfeeding woman

  • Additionally, the number of units injected is an estimate amount of Botulinum A Toxin required to paralyse the muscles. I understand there is no guarantee of results of any treatment


l understand and agree that all services rendered to me are charged directly to me and that l am personally responsible for payment. I further agree in the event of non-payment, to bear the cost of collection, and/or court cost and reasonable legal fees, should this be required.I acknowledge and fully understand all that has been explained to me.

MEDICAL HISTORY & CURRENT MEDICAL CONDITIONS 

Please check any health conditions which you have ever had previously or are now experiencing. (If Yes to any of the following please detail in the box below)

Are you currently in good health?
YES
NO
Do you carry a warning card, an EpiPen, or have you ever had an anaphylaxis reaction?
YES
NO
Are you currently under a specialist, hospital or doctor's care?
YES
NO
Do you use ANY medication, herbal/natural supplements or topical creams on a regular basis?
YES
NO
Do you have ANY allergies to medications, food, latex, or other substances?
YES
NO
Have you had any cold sore breakouts (oral herpes) in the past year?
YES
NO
Do you have a history of Keloid Scarring?
YES
NO
Any blood-borne diseases?
YES
NO
Are you, or could you be pregnant?
YES
NO
Are you breastfeeding?
YES
NO
Are you going through IVF?
YES
NO
Any recent vaccinations (including Covid), cortisone injections or steroids?
YES
NO
Replacements, implants, operations, X-rays recently?
YES
NO
Any other diseases, illnesses or treatments?
YES
NO
Do you suffer with Acne, or have you taken medication for Acne in the past 6 months?
YES
NO
Have you ever had cancer?
YES
NO
Do you have ANY current or chronic medical illness, including: Myasthenia Gravis, Amyotrophic Lateral Sclerosis or any other Neuromuscular disorders?
YES
NO
Do you have an autoimmune disease? (e.g. Crohn's disease)
YES
NO
A stroke or any other blood pressure problems?
YES
NO
Deep skin peeling?
YES
NO
AIDS/HIV?
YES
NO
Asthma, Eczema or other allergic disease?
YES
NO
Angina, murmur, valve or other heart conditions?
YES
NO
Have you ever had eyelid or facial surgery?
YES
NO
Any neurological conditions such as epilepsy, Bell's Palsy, MS, Chorea or Myasthenia Gravis?
YES
NO
Jaundice, Hepatitis, Liver or kidney disease?
YES
NO

Current Medical Status

1. Taking medicines, pills, tablets, ointments or inhalers?
YES
NO
2. Use therapies or Supplements such as St. John’s Wort?
YES
NO
3. Do you bruise or bleed easily?
YES
NO
4. Any circulative problems or varicose veins?
YES
NO
5. Any endocrine disorders? (Diabetes, thyroid)
YES
NO
6. Do you follow a healthy diet?
YES
NO
7. Do you take regular exercise?
YES
NO
Fuide intake -please tick:
9. Have you had electrical facial treatments before?
YES
NO

By signing below l acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks.

Have you previously received BOTOX/ DERMAL FILLER injections?
YES
NO

BOTULINUM RESULTS

I am aware that full correction is important and that follow-up enhancement treatments will be needed to maintain the full effects. l am aware that the duration of treatment is dependent on many factors including but not limited to: age, sex, tissue conditions, my general health and lifestyle conditions, and sun exposure. The correction, depending on these factors may last 3 months and in some cases shorter and some cases longer. I have been instructed in and understand post-treatment instructions and have been given a copy of them.

I hereby voluntarily consent to treatment. The procedure has been explained to me.


I have read the above and understand it. My questions have been answered satisfactorily. l accept the risks and complication of the procedure. certify that if I have any changes occur in my medical history, I will notify the clinic. I have read this informed consent and certify that I understand its contents in full. I have had enough time to consider the information from my practitioner/trainee and feel that | am sufficiently advised to consent to this procedure. I hereby give my consent to this procedure and have been asked to sign this form after my discussion with the practitioner/trainee. I will follow all aftercare instructions as it is crucial I do so for healing. I hereby release the practitioner/trainee, the person(s) injecting the Botulinum A Toxin and the facility from liability associated with this procedure.

PRACTITIONER ONLY


I confirm that I have fully informed the patient about the risks and benefits of treatment with Botulinum Toxin and believe they understand all the information given.

They have also been informed of alternative treatment for their presenting complaint.

Date

Welcome to home of Non Surgical transformation!

I am a Level 7 Aesthetic Practitioner and skin specialist along with being a respected Educator, International Judge, Non-Stop Speaker, I holds the esteemed title of UK's  Best Semi Permanent Make-Up Artist of the Year by the British Hair and Beauty Awards, my expertise in PMU is recognised and celebrated. With comprehensive training globally and highest accredited educators in the industry My Team and I strive for perfection and to up hold the highest clinic standards for health and hygiene, while running a successful PMU & Aesthetics Clinic.

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