BOTULINUM TOXIN – Informed Consent
Purpose
The purpose of this form is to provide written information regarding the risks, benefits and alternatives associated with the administration of BOTULINUM TOXIN (Botox, Xeomin, Dysport). Botulinum Toxin is used in the correction of mild to moderate facial lines, wrinkles, muscle tension, headaches related to muscular movement, bruxism, dystonia, spasticity, pain, etc. All therapeutic and cosmetic procedures carry risks and may cause complications. The purpose of this document is to make you aware of the nature of the procedure and its risks in advance so that you can decide whether to proceed with the procedure. This material serves as a supplement to the discussion you have with your healthcare provider. If you have any questions regarding the procedure, ask your healthcare professional prior to signing the consent form.
Procedure
Botulinum Toxin is a neurotoxin produced by the bacterium, Clostridium Botulinum. This can relax the muscles of the face and neck which cause wrinkles associated with facial expressions or facial pain. Whether for cosmetic or therapeutic treatment, these injections can reduce your facial expression lines or wrinkles. Botulinum Toxin is diluted to a very controlled solution and is injected into the muscles with a very thin needle. Patients may feel a slight burning sensation while the solution is being injected. The procedure may take around 20-30 minutes and the results can last up to 3-6 months. With repeated treatments, the results may tend to last longer.
The most frequently treated facial areas are:
A) Frown lines between the eyes (Glabella)
B) Crow’s Feet (areas to the side of the eyes)
C) Forehead lines (Rhytids)
E) Bunny Lines (side of the nose)
F) Radial Lip Lines (smoker’s lines)
G) Marionette lines (sides of the lower lips)
H) Gummy smiles
I) Cauliflower chin (Mental crease/folds)
J) Nefertiti lift (Lower jaw, and neck muscles)
Risks and Complications
No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks that are not included on this list. Post treatment discomfort, swelling, redness, and bruising. Most people tend to have a lightly swollen pinkish bump at the injection site for a few hours or even several days. Ptosis (drooping) of the eyebrow, eyelid, lower lip may occur sometimes and this usually lasts 2-3 weeks. While local weakness of the injected muscles is representative of the expected pharmacological action, weakness of the adjacent muscles may occur as a result of the spread of the toxin. In some cases, there may be the inability to blink, double vision, weakened tear duct, and corneal exposure. Post treatment bacterial, and/or fungal infection may occur that may require further treatment. Allergic reaction, occasional numbness of the forehead lasting up to 2-3 weeks, transient headaches, and flu-like symptoms may occur.
Treatment Alternatives
This is a voluntary cosmetic/therapeutic procedure. Alternative treatments include (but are not limited to) dermal fillers, facial resurfacing treatments, laser therapy, chemical peels, bite splints, muscle relaxants, etc. Ideally, seek further medical opinions should you not be satisfied with the information provided.
Pre-Treatment Instructions
It is important to follow some simple guidelines before Botulinum Toxin injection treatment. Following these instructions can produce a better result, minimise any risk, complications or side effects to the patient that may be associated with these injections. Please advise us whether you are in good health with no active skin infections in the areas to be treated. Please avoid wearing any facial make-up on the day of your treatment. Please discuss any needle phobia and pain management prior to having the injections. Avoid any alcoholic beverages for 24 hours prior to treatment as this may thin the blood and may increase the risk of bleeding, bruising, or swelling. Please advise us whether you are taking any anti-inflammatory medications (eg Asprin, ibuprofen, Naproxen, Rofecoxib), blood thinning medications (Warfarin), supplements, Vitamin E, Gingko Biloba, St. John’s Wort as these may increase the risk of bleeding, bruising or swelling. Schedule your Botulinum Toxin injection appointment at least 2 weeks prior to a special event that may be occurring, e.g., wedding, vacation, important photo opportunity, etc. Results typically begin to take effect approximately 5-10 days following treatment and may even sometimes take 2 weeks to reach their full effect. Bruising may last up to several days or occasionally weeks following these injections as this is very individualised for each patient.
Post-Treatment Instructions
It is important to follow some simple guidelines after Botulinum Toxin injection treatment. This treatment targets specific muscles of the face and neck to cause them to relax. Although side-effects are never completely avoidable, there may be a risk of side-effects such as ptosis (drooping of the eyelids, eyebrows, lips), or relaxation of other undesirable muscles. Avoid exercise, heavy lifting, or physical straining of the face for 4 hours after treatment. The Botulinum Toxin takes approximately 2 hours to bind to the nerve before it starts to work. Avoid manipulation of the facial treatment area for 4 hours following the treatment and try and keep the head in an erect posture as long as possible as we do not want to increase circulation to that area that may cause rapid diffusion of the injection. Avoid any facial waxing, threading, facials, lasers, peels, or microdermabrasion for up to 24 hours following treatment. A facial, peel, or microdermabrasion can be done in same day but only if is done before the injections. Avoid applying makeup for at least 12 hours as that may clog the injection sites with oils or bacteria. Avoid sun and heat exposure (including sunbathing, sauna, hot yoga, etc.) for 24 hours following treatment as this may deactivate the ingredient, hence rendering the treatment less or non-effective. It can take 5-10 days for the injection to take full effect and it is recommended that the patient contact the office should any unexpected side-effects occur.
Medical Questionnaire
Do you suffer or have ever suffered from any of the following conditions? (If ‘YES’ then please tick and provide further information, if ‘NO’ then move onto the next question)
High blood pressure Diabetes Heart disease Neurological disease
Epilepsy Psychiatric Blood conditions Skin disease
Liver/Kidney disease Thyroid disease Vascular disease Infections
Cold sores Migraines Other:
Female patients: (If ‘YES’ then please tick and provide further information, if ‘NO’ then move onto the next question)
Are you pregnant or actively trying for conception?
Are you breast-feeding?
Do you suffer from allergies? (If ‘YES’ then please provide further information, if ‘NO’ then move onto the next question)
Are you taking any medications that are listed on this document? (If ‘YES’ then please provide further information, if ‘NO’ then please continue reading)
The patient accepts that there is no guarantee of aesthetic or therapeutic results, apart from the fact that the health practitioner will use their best efforts and judgment for the benefit of the patient.
The patient consents to receive the treatment. This consent includes future treatments aimed at improving the results of the first treatment (called “top-ups”), and this informed consent shall remain valid for 1 year from the date shown at the bottom of this document. The patient understands the pre-operative and post-operative instructions that needs to be followed and all the risks and complications mentioned in this document. The patient understands and accepts that the results of the treatment can last between 3 and 6 months and results may vary between treatments but in some patients with more powerful facial musculature, it is possible that no or minimal muscle relaxation may occur. The patient understands and accepts that the results of the treatment may take 5 or 10 days to appear, and in certain cases it may take up to 21 days. The patient understands and accepts that after having the injections, inflammation, redness, or bruising may appear, and that if the patient has previously suffered from cold sores, the treatment may trigger a new occurrence. The patient understands and accepts that there is a risk, although minimal, of developing an infection due to the treatment. The patient understands and accepts that there is a risk, although minimal, of suffering an allergic reaction to the injections, medications or topical products used in the treatment. The patient understands and accepts that there is a risk, although minimal, of suffering temporary weakness (ptosis) of the eyelids, the eyebrows, or lower lip and that it may last a maximum of 3 to 6 months. The patient declares that they do not suffer from any neurological disease that affects muscle motility (for example, myasthenia gravis, Eaton-Lambert syndrome, any other myopathies, etc.) and that they are not currently taking Calcium blockers, anticoagulants, spectinomycin, penicillin, tetracyclines, quinine or quinolones (ciprofloxacin, ofloxacin), etc.). The patient (in case of being female) declares that she is not pregnant, that she is not actively trying to get pregnant and that she is not breastfeeding. The patient declares to have mentioned to the health practitioner all the relevant medical information regarding their health condition. The patient declares that they have been informed in detail about the risks and possible complications of the treatment, and that they have had the opportunity to present any doubts to the health practitioner. The patient consents to being photographed. The patient understands and accepts that the photographs will be the property of the practice, and that they may be used for before and after comparisons, research, publication, or teaching purposes. Please inform the health practitioner should you wish not to be photographed. The patient declares that, before signing this document, they have read it and fully understands its contents.
Name:
Mobile No:
Signature:
Date:
DERMAL FILLERS – Informed Consent
Purpose
The purpose of this form is to provide written information regarding the risks, benefits and alternatives associated with the administration of DERMAL FILLERS (Juvederm, Restylane, Revanesse, etc). Dermal fillers are used in the correction of moderate to severe facial wrinkles, folds, and volume loss. All therapeutic and cosmetic procedures carry risks and may cause complications. The purpose of this document is to make you aware of the nature of the procedure and its risks in advance so that you can decide whether to proceed with the procedure. This material serves as a supplement to the discussion you have with your healthcare practitioner. Should you have any questions regarding the procedure, please consult with your healthcare practitioner prior to signing the consent form.
Procedure
Dermal fillers are a gel-like dermal implant made of hyaluronic acid (a substance naturally occurring in the human body that can absorb up to 1000 times its weight in water). Facial rejuvenation can be carried out with minimal complications. These dermal fillers are injected under the skin with a very fine needle. This produces volume under the skin to lift and smooth wrinkles and folds. The results can often be seen immediately and last up to 6 months depending on the type of filler used and the site. This product is administered via injection using a thin gauge needle, into the areas of the face to be filled with dermal filler to eliminate or reduce wrinkles and folds. The treatment site is cleaned of all surface debris and makeup with an antiseptic wipe. Multiple injections may be given depending on the site, depth of the wrinkle/fold and technique used. Following each injection, the site may be massaged to adapt the filler to the contour of the surrounding tissues. If the treated area is swollen directly after the injection, ice may be applied on the site for a short period of time. After the first treatment, additional treatments may be necessary to achieve the desired level of correction. Full correction is not guaranteed after one treatment, and complete symmetry may not be achieved in some cases. Dermal fillers are temporary and are naturally dissolved by the body over time. Results may vary from one treatment to another.
Risks and Complications
No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks that may occur and are not included on this list. Post treatment discomfort, swelling, redness, bruising, and discoloration may occur. Although a very small needle is used, common injection related reactions may occur. Effects may include initial swelling, pain, itching, discoloration, bruising or tenderness at the injection site. These reactions generally lessen or disappear within a few days but may last for a week or longer. You may experience increased bruising or bleeding at the injection site if you are using substances that reduce blood clotting such non-steroidal anti-inflammatory drugs such as aspirin, Ibuprofen etc. Post treatment infection associated with any transcutaneous injection may occur. The syringe is sterile and standard precautions associated with injectable materials have been taken, but infection at the injection site is a possibility. Some visible lumps may occur temporarily following the injection. After the swelling has gone down, you may be able to feel bumps, but they should no longer be visible. Occasionally visible yellow or white patches may occur. Granuloma formation may occur in some patients, and they may experience additional swelling or tenderness at the injection site and on rare occasions, pustules may form. These reactions might last for as long as two weeks. Allergic reactions may be associated with dermal fillers, gloves, topical creams, etc. and should not be used in patients who have experienced hypersensitivity previously. Care should be taken with those patients with severe allergies to latex or xylocaine products (including but not limited to xylocaine, novocaine, zylocaine, benzocaine, prilocaine, or tetracain). Reactivation of herpes (cold sores) may occur, and dermal fillers should not be used in areas with active inflammation or infections (e.g. cold sores, cysts, pimples, rashes or hives) Localized necrosis or ulcerations secondary to vessel compression/occlusion may occur in a very small percentage of patients. In some instances, referral to a specialist or hospitalization may be indicated. If you are considering laser treatment, chemical peels or any other procedure based on a skin response after dermal fillers, or if you recently had such treatments and the skin is not healed completely, there is a possible risk of an inflammatory reaction at the implant site. Most patients are pleased with the results of dermal fillers. However, like any cosmetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that wrinkles or folds will disappear completely, or that you may require additional treatments to achieve the desired result. While the effects of dermal fillers can last longer than other comparable treatments, the procedure is still temporary. Additional treatments will be required periodically, generally within 6 months to a year, involving additional injections for the effects to continue. After treatment, you should minimize exposure of the treated area to excessive sun or UV lamp exposure and extreme cold weather until any initial swelling or redness has gone away.
Treatment Alternatives
This is a voluntary cosmetic/therapeutic procedure. Alternative treatments include (but are not limited to) Botulinum toxin, facial resurfacing treatments, laser therapy, chemical peels, bite splints, orthodontics, etc. Ideally, seek further medical opinions is you are not satisfied with the information provided.
Pre-Treatment Instructions
It is important to follow some simple guidelines before receiving dermal filler injection treatment. Following these instructions can produce a better result, minimise any risk, complications or side effects to the patient that may be associated with these injections. The patient should be in good overall health. A medical and dental history may need to be performed for optimal results. Please avoid wearing any facial make-up on the day of your treatment. Please let us know if you are prone to cold sores. A pre-operative medication may help prevent cold sores after treatment. If you develop a cold sore, blemish, or rash, etc. prior to your appointment, you will need to reschedule your appointment. Please give at least 24-hour’s notice prior to cancelling or rescheduling your appointment. If you have any concerns that you are not sure about, please contact us for clarification. If you have a special event or vacation coming up, please schedule your treatment at least 2 weeks in advance. This will allow time for the swelling and bruising to dissipate in order for you to see the full effect of your results. Avoid certain anti-inflammatories, if possible (Gingko Biloba, Garlic, Linseed Oil, Cod Liver Oil, Vitamin A, Vitamin E, or any other essential fatty acids), at least 3 days to 1 week before and after treatment. This will help to minimize bruising and swelling. Try to avoid alcohol, caffeine, niacin supplements, high-sodium foods, high sugar foods, refined carbohydrates, spicy foods, and cigarettes 24-48 hours before and after your treatment. Do not schedule any facials, facial waxing, threading, peels, lasers, microdermabrasion for at least 24 hours after your treatment.
Post-Treatment Instructions
Below are guidelines to follow after your dermal filler (Juvederm, Restylane, Revanesse, etc.) treatment. Filler treatment targets volume loss, wrinkles, folds, lip volume, and facial asymmetries. Though side-effects are never completely avoidable, to minimize your risk of side-effects such as bruising, swelling, or drifting of filler beyond treatment area, please follow these guidelines:
Do not touch, press, rub or manipulate the implanted areas for the rest of the day after treatment.
Avoid kissing, puckering and sucking movements for the rest of the day as these motor movements can undesirably displace the implanted dermal filler material. You may cause irritation, sores, and possible scarring if you do.
Avoid certain anti-inflammatories, if possible, (Gingko Biloba, Garlic, Linseed Oil, Cod Liver Oil, Vitamin A, Vitamin E, or other essential fatty acids), at least 3 days after treatment. Avoid alcohol, caffeine, niacin supplements, high-sodium foods, high sugar foods, refined carbohydrates, spicy foods, and cigarettes 24-48 hours after your treatment.
Avoid vigorous exercise and sun and heat exposure for at least 3 days after treatment.
It is best to wear no makeup or lipstick until the next day. Earlier use may cause an infection or pustules.
One side may heal faster than the other side causing the appearance of temporary asymmetry.
You can expect some bruising and swelling around the areas that were injected. Apply ice for short periods of time for the first hour after treatment.
Wait a minimum of 2 weeks before deciding on any enhancements to be made to allow any swelling to completely resolve.
Please contact us should any redness, blisters, or itching persist.
Medical Questionnaire
Do you suffer or have ever suffered from any of the following conditions? (If ‘YES’ then please tick and provide further information, if ‘NO’ then move onto the next question)
High blood pressure Diabetes Heart disease Neurological disease
Epilepsy Psychiatric Blood conditions Skin disease
Liver/Kidney disease Thyroid disease Vascular disease Infections
Cold sores Migraines Other:
Female patients: (If ‘YES’ then please tick and provide further information, if ‘NO’ then move onto the next question)
Are you pregnant or actively trying for conception?
Are you breast-feeding?
Do you suffer from allergies? (If ‘YES’ then please provide further information, if ‘NO’ then move onto the next question)
Are you taking any medications that are listed on this document? (If ‘YES’ then please provide further information, if ‘NO’ then please continue reading)
The patient accepts that there is no guarantee of aesthetic results, apart from the fact that the health practitioner will use their best efforts and judgment for the benefit of the patient.
The patient consents to receive the treatment with dermal fillers for facial rejuvenation, lip enhancement, establish proper lip and smile lines, and replacing facial volume. This consent includes future treatments aimed at improving the results of the first treatment (called “top-ups”), and this informed consent shall remain valid for 1 year from the date shown at the bottom of this document. The patient understands and accepts that the results of the treatment can last between 4 and 6 months. The dermal filler procedure is temporary and additional treatments will be required periodically, involving additional injections to maintain the full effects.
The patient understands that the treatment is dependent on many factors including but not limited to age, sex, tissue conditions, general health, lifestyle conditions, and sun exposure. The correction, depending on these factors, may last up to 6 months and in some cases shorter and some cases longer. The patient understands the pre-operative and post-operative instructions that needs to be followed and all the risks and complications mentioned in this document. The patient understands and accepts that after the injections, inflammation, redness or bruising may appear, and that if the patient has previously suffered from cold sores, the treatment may trigger a new infection. The patient understands and accepts that there is a risk, although minimal, of developing an infection due to the treatment. The patient understands and accepts that there is a risk, although minimal, of suffering an allergic reaction to the injections, gloves, medications or topical products used in the treatment. The patient (in case of being female) declares that she is not pregnant, that she is not actively trying to get pregnant and that she is not breastfeeding. The patient declares to have mentioned to the health practitioner all the relevant medical information regarding their health condition. The patient declares that they have been informed in detail about the risks and possible complications of the treatment, and that they have had the opportunity to present any doubts to the health practitioner.
The patient consents to being photographed. The patient understands and accepts that the photographs will be the property of the practice, and that they may be used for before and after comparisons, research, publication, or teaching purposes. Please inform us should you wish not to be
photographed.
The patient declares that, before signing this document, they have read it and fully understands its contents.
Name:
Mobile No:
Signature:
Date: