I confirm that, who uses Botulinum Toxin Type A for cosmetic treatments, has given me sufficient information to enable me to understand the use of the product. I have received information regarding the products contraindications and possible side effects. I have been given the opportunity to ask questions about the proposed treatment.

When completing the medical history questionnaire, I have answered the questions fully and to the best of my ability. I have also given further details relating to my medical history when asked.

I CONFIRM I HAVE BEEN INFORMED THAT:
Botulinum Toxin Type A is injected into the skin to correct lines and wrinkles (in certain areas this treatment is used off licence). Due to the use of a needle, there may be some bleeding or bruising at the injection site

POSSIBLE SIDE EFFECTS:
Like all medicines, Botulinum Toxin Type A can produce unwanted effects.
Adverse reactions possibly related to the spread of toxin distant from the site of administration have been reported very rarely with Botulinum Toxin (e.g. muscle weakness, difficulty to swallow or pneumonia due to unwanted food or liquid in the airways).
In general, adverse reactions occur within the first few days following injection and are temporary. Most adverse events are of mild to moderate severity.
As expected for any injection procedure, pain/burning/stinging, swelling and/or bruising may be associated with the injection. Speak to your practitioner if you are worried about this.

Common side effects are: (classified as more than 1 out of 100 persons and less than 1 out of 10)
◆ headaches ♦ drooping eye lid ♦ skin redness♦ localised muscle weakness ♦ face pain

Uncommon side effects are: (classified as more than 1 out of 1,000 persons and less than 1 out of 100)
◆ infection ♦ anxiety ♦ numbness ♦ dizziness ♦ inflammation of the eyelid ♦ eye pain ♦ visual disturbance ♦ swelling (face, eyelid, around the eyes)

Allergic reactions, difficulties to swallow, speak or breathe, have been reported rarely when Botulinum Toxin Type A has been used for other uses. Visit your doctor immediately if such signs develop after any Botulinum Toxin treatment.

I agree that after treatment I will avoid alcohol consumption, strenuous physical activity and touching the area for 6 hours and avoid lying down for 4 hours.

I understand that the practice of medicine and surgery is not an exact science and therefore that no guarantee can be given as to the results of the treatment referred to in this document. I accept and understand that the goal of this treatment is improvement, not perfection, and that there is no guarantee that the anticipated results will be achieved
Consent to the treatment detailed on this form.I confirm that I have answered this to the best of my ability.