Botox consent

PATIENT HISTORY AND CONSENT FORM – BOTULINUM TOXIN

For your safety and comfort, please answer the following medical questions accurately. Please discuss anything you are unsure of with your Dentist as this may have a bearing on the treatment you receive.

 

NAME

______________________________________________

DATE OF BIRTH

__________

 

ADDRESS

__________________________________________________________________________

 

TELEPHONE

______________________________________________

TODAY’S DATE

___________

 

Please tick if you experience, or have experienced in the past:

 

  1. Allergies – notably to Sodium Chloride, Botox or Human Albumin: ___________________________

  2. Severe allergy or Anaphylaxis

  3. Herpes

  4. Acne

  5. Skin cancer or other skin conditions e.g. Psoriasis

  6. Diabetes

  7. Neuromuscular disorders – e.g. myasthenia gravis, Eaton-Lambert syndrome, multiple sclerosis

  8. Cheloid / Hypertrophic scarring

  9. Any other medical conditions: _______________________________________________________

 

Are you currently

  1. Breast-feeding?

  2. Pregnant?

 

Please tick if you have received any of the following in the past 3 months:

 

  1. Antibiotics – notably Spectinomycin, Gentamycin, Clindamycin:_______________________________________________

  2. Non-Steroidal Anti-Inflammatory Drugs (NSAIDS): __________________________________________________________

  3. Anti-coagulant therapy – e.g. Warfarin, Heparin, Aspirin:_____________________________________________________

  4. Health supplements – e.g. Vitamin E, Omega-3 Fish Oils:_____________________________________________________

  5. Corticosteroids

  6. Muscle Relaxants

  7. Any other medications: _______________________________________________________________________________

 

 

Previous Treatment

 

Have you previously received any of the following?  If so, please list the date, product, dosage used.

 

  1. Botox / Dysport / Dermal Filler injections _________________________________________________

  2. Facial treatments – e.g. laser, micro-dermabrasion ________________________________________

  3. Botulism food poisoning _____________________________________________________________

 

If you answered yes to any of the above, did you experience any problems or reactions to the treatment provided and were you happy with the results?

 

 

 

Authorisation

I, (patient)

________________________________________________________________________________

 

Hereby authorise

 

(Dentist)

________________________________________________________________________________

 

 

To perform injections of Botulinum Toxin A for the

 

Correction of

________________________________________________________________________________

I fully understand and acknowledge that

Treatment with Botulinum Toxin A, such as that which has been prescribed for me, is a medical procedure that carries with it certain potential complications and side effects, both local and systemic. I understand that when small amounts of purified Botulinum Toxin A are injected into a muscle it causes weakness or paralysis of that muscle and will affect my ability to utilize the muscle for facial expression or function.

 

I have received detailed information, in clear terms, regarding the product’s contraindications, potential complications and side effects; I have been given the opportunity to ask questions about the proposed treatment; and I now fully understand and accept the benefits, risks, complications and side effects, both immediate and long - term, general and specific, which this procedure may cause.

 

These include, but are not limited to, pain, swelling, redness, burning/stinging, tenderness, bleeding and bruising at the site of injection, post-operative headache, ptosis of the eye -lids or eyebrows, nausea, flu-like symptoms, local muscle weakness, paraesthesia, undesired effect on other facial muscles causing unwanted effects and rarely serious allergic reaction/anaphylaxis.

 

When completing the medical history, I have done so to be best of my knowledge and have not willingly withheld any information. I understand that treatment is temporary in nature and will require re -treatment after an average of 3-4 months, though this will vary depending on various personal circumstances.

 

I have been informed that medical treatment is not an exact science and that no guarantees can or have been made with respect to the expected results and that further treatment may be required to achieve the desired outcome.

 

Signatures

Patient

 

Dentist