Botox & Filler Consent Form

Medical history

Botox & Filler Consent Form
Name*

First NameLast Name
Date of Birth*

DayMonthYear
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Please select any conditions that apply to you:

Rheumatic feverPacemakerEpilepsyI have an autoimmune disease (diabetes, lupus, HIV/AIDS, MS, psoriasis, rheumatoid arthritis)Heart problemsLiver or Kidney diseaseAsthmaHeart murmurHigh blood pressureHepatitisHayfeverBleeding disorderHeart surgeryBlackouts/ Fainting attacks/ GiddinessI have a history of oral herpes/cold soresBad reaction to local anaestheticHospitalised for any operations/serious conditions in last 5 yearsTaken steroids in last 2 yearsCarry a medical warning card/braceletI bruise easilyI take immunosuppressants
I have these allergies:
I take these pills/medications:
If female, are you or do you think you may be pregant?
Do you smoke?

Yes, less than 5 cigarettes per dayYes, more than 5 cigarettes per dayNoVery rarely and only socially
If you smoke, how many years have you smoked for?
How many units of alcohol do you drink per week?
Name and address of your doctor:*
I consent to sharing of information with my GP where necessary.
Please select any conditions that apply to you (contraindications for botox):

Pregnancy or breast-feedingActive infection in the treatment area (eg herpes simplex, pustular acne, cellulitis)Hypertrophic or Keloidal scarringBleeding abnormality (eg thrombocytopenia, anticoagulant use)Impaired healing (eg immunosuppression)Skin atrophy (eg chronic oral steroid use, ehlers danlos syndrome)Active dermatoses in the treatment area (eg psoriasis, eczema)Sensitivity or allergy to constituents of botulinum toxin (inc. botulinum toxin serotype a, human albumin, lactose or sodium succinate)Milk allergy with abobotulinumtoxinA productsGross motor weakness in the treatment area (eg polio, Bell's palsy)Neuromuscular disorder inc. but not limited to amyotrophic lateral sclerosis, myasthenia gravis, lambert-eaton syndrome and myopathiesInability to contract muscles in the treatment area prior to treatmentPeriocular or ocular surgery within the last 6 monthsMedications that inhibit neuromuscular signalling and may potentiate botulinum toxin effects (eg aminoglycosides, penicillamine, quinine, calcium channel blockers)Uncontrolled systemic conditionOccupation requiring uncompromised facial expression (eg actors, singer)Unrealistic expectations or body dysmorphic disordersSevere needle phobiaNone of the above
Please select any conditions that apply to you (contraindications for fillers):

Pregnancy or breast-feedingInfection in the treatment area (e.g. Herpes simplex, acne)Hypertrophic or Keloidal scarringBleeding abnormality (eg thrombocytopenia, anticoagulant use)Roaccutane use within the last 6 monthsSkin atrophy (eg chronic steroid use, genetic syndromes such as ehlers-danlos syndrome)Impaired healing (eg due to immunosuppression)Dermatoses active in the treatment area (eg vitiligo, psoriasis, eczema)Uncontrolled systemic conditionPrevious anaphylactic reactionMultiple severe allergiesSensitivity or allergy to constituents of dermal filler productsBody dysmorphic disorderUnrealistic expectationsNone of the above
Dermal Fillers consent Form Dermal fillers are used for the treatment of facial creases, wrinkles, folds, contour defects, depression scars, facial lipoatrophy (loss of fat) and enhancement purposes. These treatments involve multiple injections of filler into or below the skin to fill wrinkles and restore volume. The effects of dermal fillers are temporary and no guarantees can be made regarding how long correction will last in a specific patient. Alternatives to temporary fillers include, but are not limited to: permanent dermal fillers, laser resurfacing and skin tightening, surgical facelift or no treatment at all. Possible risks, side-effects, and complications with dermal fillers include but are not limited to:
- Bruising, redness and swelling
- Visible raised areas or bumpiness at/around the treated site
- Asymmetry, over correction or under correction.
- Unpredictable persistence of filler, either shorter or longer than anticipated
- Prolonged discolouration of the skin such as brown, greyish, bluish or reddish colouration.
- Filler material may be extruded from the skin in rare cases
- Prolonged or severe swelling Infection
- Rarely granulomas or firm nodules may form
- Benign tumour formation (keratoacanthomas)
- Allergic reaction with itchiness, redness and in extremely rare cases generalised allergic response such as a whole body swelling, respiratory problems and shock
- Scarring is extremely rare Skin breakdown or ulceration
- Tissue necrosis is extremely rare
- Blindness
Botox Consent Form Injection of botulinum toxin causes weakness of targeted muscles, which can last approximately 2-4 months and over this time the effects will diminish. Injection of small amounts of botulinum toxin relaxes the treated muscles and can reduce facial wrinkles such as frown lines. It is injected with a small needle into the targeted muscles. Effects are typically seen in a few days and can take 1-2 weeks to fully develop.

For most complications associated with Botox there are no corrective treatments and they spontaneously resolve as botulinum toxin effects diminish.

Botulinum toxin-related side effects can include, but are not limited to:
- Localised burning or stinging pain during injection
- Blepharoptosis (droopy eyelid)
- Eyebrow ptosis (droopy eyebrow)
- Ectropian of the lower eyelid (eyelid margin eversion)
- Lagophthalmus (incomplete eyelid closure)
- Xerophthalmia (dry eyes)
- Epiphora (excess tearing) Diplopia (double vision)
- Impaired blink reflex Photophobia (light sensitivity)
- Globe trauma Infraorbital festooning (worsening of eyebags)
- Lip ptosis with resultant smile asymmetry
- Oral incompetence with resultant drooling and impaired speaking, eating or drinking
- Cheek flaccidity Dysarthria (difficulty articulating)
- Dysphagia (difficulty swallowing)
- Hoarseness Neck weakness
- Facial asymmetry, alteration or poor aesthetic result
- Inadequate reduction of wrinkles or lack of intended effect in the treatment area
- Worsening wrinkles in areas adjacent to the treatment area
- Weakening muscles adjacent to the treatment area
- Autoantibodies against botulinum toxin. Autoantibodies may be present or develop after injection, rendering treatments ineffective (1-2% of patients treated for cosmetic indications)
- Extremely rare, immediate hypersensitivity reaction with signs of urticaria, oedema and a remote possibility of anaphylaxis
- General Injection-related complications (can be any treatment):
  - Pain
  - Bruising
  - Erythema
  - Oedema
  - Tenderness
  - Headache
  - Infection
  - Numbness or paresthesia
  - Anxiety
  - Vasovagal episode and loss of consciousness
BOTOX PRE-TREATMENT INSTRUCTIONS

•To minimize the possibility of bruising, non-essential blood-thinning medications or supplements should be discontinued for 10-14 days prior to treatment if possible. These include aspirin, ibuprofen, Advil, Motrin, Midol, Aleve, Excedrin, Alka-Seltzer, vitamin E, green tea, garlic, gingko biloba, ginseng, and St. John’s wort. Please note that if you have been prescribed aspirin or another blood thinning medication such as Plavix or Coumadin for medical reasons, do NOT discontinue these medications. Please be advised the bruising does not affect the success of treatment.

•BOTOX® injections are generally very well tolerated with minimal discomfort. The use of a topical anesthetic is optional and generally not required. If you wish to apply a topical anesthetic at home, please notify your physician for a prescription.

•If you are pregnant, breast-feeding, or trying to become pregnant, please alert your physician, as you are not a candidate at this time.

•If you are unable to keep your appointment, please call (441)236-9375 to cancel or reschedule. Patients will be charged for any missed appointment that is not cancelled at least 48 business hours in advance.

BOTOX POST-TREATMENT INSTRUCTIONS

•Do not lie flat for at least four hours after your treatment. After four hours, you may resume your normal activities, however, avoid any exercise for at least 24 hours.

•Do not touch, massage, or in any way manipulate the injection sites. To minimize redness and bruising, avoid anything that will make your face or body flush such as direct sunlight, exercise, alcohol, hot showers, or spicy foods for 24 hours. If bruising does occur, it will go away in several days.

•You may apply cool water compresses to the treatment sites if they are uncomfortable or red.

•If you develop a headache, Tylenol is permissible. Do not take aspirin or ibuprofen as these agents may increase the risk of bruising.

•To enhance the uptake of BOTOX®, contract the muscles in the treated area frequently for two to three hours after treatment.

•As every patient has a different facial anatomy, asymmetry of the treatment result can occur with BOTOX® injections. Sometimes the correction is less than what you had expected, or wanes quicker than you had expected. Additional treatments may be required to try to meet your expectations. Please call our office to be seen for follow-up should any of these concerns arise.

•If you develop a droopy eyebrow or eyelid, do not be alarmed. This uncommon side effect is not serious. You should call our office, as there are eye drops that can be prescribed which will alleviate this problem. This problem generally resolves in several weeks to several months. If you experience any signs or symptoms that you are concerned about, please do not hesitate to call Toothworx at (441)236-9375.
My signature below certifies that I have fully read this consent form and understand the written information provided to me regarding the proposed procedure. I have been adequately informed about the procedure including: the potential benefits, risks, limitations and alternative treatments and I have had all questions answered to my satisfaction.
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Medical history