Botulinum Toxin Treatment Consent Form
Sign in to Google to save your progress. Learn more
Your full name & Surname *
Please confirm, that you have filled Form No. 1 - General Information & Medical Questionnaire. (If no, head back to the form no.1)
Have you had before any dermal fillers or botulinum toxin treatment? 
If yes, which treatment in what areas, and when did you have the treatment?
Have you a history of severe allergy/anaphylaxis to botulinum toxin type A or its excipients?
Do you suffer from myasthenia gravis or Eaton Lambert syndrome?
Please read below potential risk, side effects, and after-care procedure:
Risks and Side Effects

Common Risks – 1 in 100 to 1 in 10
• Redness
• Swelling
• Bruising
• Allergic reaction
• Headache
• Pain
• Eyelid droop
• Eyebrow droop
• Muscle weakness
• Unsatisfactory result

Uncommon Risks – 1 in 1,000 to 1 in 100
• Injection
• Antibody formation
• Nausea
• Numbness
• Eye pain
• Skin tightness/dry skin
• Paraesthesia (pins and needles)
• Blepharitis (inflamed eyelids)
• Flu like symptoms/fever
• Photosensitivity reactions
• Blurred/double vision
• Heaviness in eyelids
• Dry/watery eyes
• Nerve pain
• Muscle twitching

Rare Risks – 1 in 10,000 to 1 in 1,000
• Rash/hives
• Itching
• Serious allergic reaction (anaphylaxis)
• Hair loss
• Spread of product in the neck area affecting nearby muscles; difficulty in swallowing, pneumonia
• Decreased hearing
• Arrhythmias, MI
• Seizure

Area Specific Related Risks
Botox Around the Mouth

• Reduced ability to smoke, drink through a straw or whistle (peri-oral lines)
• Reduced smiling (gummy smile)
• Asmmetry (DAO, peri-oral, gummy smile) Botox in the Armpit
• Non axillary sweating, hot flushes
• Myalgia and joint pain (Less Common)

Botox in Masseter
• Muscle ache
• Reduced ability to chew
• Speech disturbance

• Improvement/reduction/eradication of facial lines (static lines require repeated treatments)
• Reduced ability to contract muscle leading to the skin remaining relaxed
• Prevention of developing or making existing wrinkles worse
• Potential reduction in headaches
• Potential smooth/shiny skin
• Brow lift
• Reduced gummy smile
• Reduction in down turn of the mouth
• Tighter jaw line
• Reduction in platysmal bands showing
• Reduced sweating
• Reduced dimpling of chin
• Slimming of masseter

• No treatment
• Dermal filler
• Dermabrasion
• Obagi/retinols
• Sculptra
• Medical Needling
• Mesotherapy
• Surgery Hyperhidrosis
• Antiperspirants
• Aluminium chloride hexahydrate
• Surgery


1. You have undergone a dermal filler treatment where hyaluronic acid has been placed in the skin. You may initially be swollen, red and bruised which will subside within the next 1 -10 days, especially if the bruising is extensive.
2. It is advisable that you do not touch the area for 6 hours.
3. Do not apply make up for approximately 6 hours unless it is mineral based.
4. Avoid exposure to UV and extreme heat i.e. sauna, steam rooms, sun beds etc. as this may increase discomfort and swelling.
5. Also avoid extreme cold: this includes ice packs that are directly applied to the skin. If necessary you can apply a cool compress to the area to reduce any discomfort or swelling.
6. Arnica tablets/gel can be used to help reduce bruising or the application of vitamin k oxide cream.
7. If you have had a local nerve infiltration injection please do not consume any hot or cold drinks until your sensation has returned to normal. You must also be careful when eating so that you do not risk biting your lip.
8. If you experience any lumpiness in the implantation area it can be gently massaged to help smooth this out.
9. You should also avoid any facial massages or skin resurfacing until the area has healed fully.
10. If you feel unsatisfied with the result, a review appointment can be arranged but any additional products used will be charged at the normal price per syringe.


I confirm that I have been informed that: Botulinum toxin is indicated for the temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at the frown (glabella lines) and for the improvement of lines around the eyes (crow’s feet) in adults <65 years old, when the severity of these lines has an important psychological impact for the patient. Any use of botulinum toxin outside of this product license is off the label use and I have discussed the implications of this with my clinician.

Like all medicines botulinum toxin can have side effects, although not everyone gets them. Approximately 1 out of 4 patients may experience side effects following a botulinum toxin injection. These adverse reactions may be related to treatment, injection technique or both.

Treatment with Botulinum Toxin is temporary, lasting approximately 3 – 6 months but will vary depending on the condition of the skin, area treated, amount of product injected, injection technique and lifestyle factors such as sun exposure and smoking. I also understand that to maintain the effects, further treatment is required.

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 airways). Injection of botulinum toxin is not recommended in patients with a history of dysphagia (difficulty to swallow) and impaired swallowing.

In general, adverse reactions occur within the first few days following injection and are temporary. Most adverse events reported were of mild to moderate severity. Diffusion of botulinum toxin into nearby muscles is possible when high doses are injected, particularly in the neck area.

The chance of having a side effect is described by the following categories:
Common – More than 1 out of 100 persons and less than 1 out of 10 persons
Uncommon – More than 1 out of 1,000 persons and less than 1 out of 100 persons
Rare – More than 1 out of 10,000 persons and less than 1 out of 1,000 persons

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 clinician immediately if such signs develop after botulinum treatment. If any of the side effects gets serious, or if you notice any side effected not listed, please tell your clinician.

Too frequent or excessive dosing of botulinum toxin may increase the risk of antibodies in the blood which may lead to failure of treatment with botulinum toxin when used for this and other conditions.

I confirm that my clinician, has:

- Discussed the risks, benefits and alternatives to this treatment
- Given me the opportunity to ask all remaining questions I have about the treatment
- Given me time to consider the treatment
- Received an accurate medical history and that I have not withheld any information
- Discussed and issued me with specific aftercare pertaining to this treatment.

I therefore consent to receiving the described treatment by my clinician.
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy