Botulinum Toxin Informed Consent (Upper Face)
Date of Birth:
Aim of Treatment: The aim of this treatment is to significantly reduce the movement of the muscles causing expression lines, thus improving the appearance of such lines. This clinic uses Azzalure/Dysport/Botox/BoCouture.
Common Side Effects Associated with the Injections Include;
Pain or stinging sensation when the injection is performed.
Localised swelling, redness, tenderness
Bleeding at the sites of injection
Numbness or itching of the area following injection.
The above usually resolve spontaneously within hours or days, but may persist for longer.
Asymmetry of expression – Perfect symmetry may not be achievable; that caused by the treatment, can often be corrected at your review appointment.
Common side effects associated with treatment with botulinum toxin to the upper face.
Eye lid ptosis (a drooping or heaviness of the eyelid, one or both), brow ptosis (heaviness and or lowering of the brow).
Uncommon Side effects
Swelling/ puffiness around the eyes
Altered skin sensation, muscle twitching or spasm in the treated area
Eye pain, dry eyes, tearing, sensitivity to light, blurred vision, strabismus
Flu like symptoms
Itching or dry skin
Muscles not targeted may be effected
*This list is not exhaustive, you may ask for a copy of the patient information leaflet in the pack, or check the Summary of Product Characteristics on-line.
Any adverse reactions usually occur within a few days of treatment. Botulinum toxin effects are not reversible. They are expected to be temporary in nature and usually resolve spontaneously within weeks. Rarely, symptoms may persist for several months.
The treatment of the brow, and any area other than frown or crows feet with botulinum toxin are not a licensed indications*(modify for brand used). The product manufacturer has no liability should a complication arise, when this medicine is used for indications that have not been licensed.
Successful treatment should prevent or significantly reduce the expressions causing the lines. Treatment may not cause the expression lines themselves to disappear completely. The expression may not be completely frozen, particularly if extreme effort is exerted to make any expression. Any decision to increase the dose, or repeat treatment, will be made at the discretion of the practitioner, informed by safety and best practice.
On occasion it is helpful to share visual images of our own treatment results.
I consent to photographs being published for;
I have been advised the cost of the treatment will be £ and accept the terms of payment as per the clinic policy (terms and conditions).
Leave this empty:
Signed by Nina Bal
Signed On: 8th January 2020
If you have questions about the contents of this document, you can email the document owner.
Document Name: Botulinum Toxin Informed Consent (Upper Face)
Agree & Sign