Name *

First Name

Last Name

Date of Birth *

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Phone *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

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Consent *

I confirm I have been informed that: • [Botulinum Toxin Type A] uses the toxin produced by the bacteria responsible for botulism in food poisoning. However, the amount of toxin used is minimal and generally well tolerated in clinical trials. The toxin temporarily weakens the muscle responsible for developing facial expression lines caused by muscle activity. Static facial lines, e.g. those due to sun damage, will not usually respond to treatment with botulinum toxin, as they are not caused by muscle activity. • [Botulinum Toxin Type A] is licensed for the temporary improvement of moderate to severe vertical lines between the eyebrows (glabellar lines) and is injected into the skin to reduce these lines. You are having these injections because the severity of your lines has had an important physiological impact on you. • Treatment is not recommended if you are pregnant or breastfeeding. • After treatment with [Botulinum Toxin Type A] you should start to see an improvement within 2 to 3 days, however the full effect can take up to 30 days. The benefits of treatment usually last between 4 and 6 months, but can vary depending on your individual response. • The most common side effects of [Botulinum Toxin Type A] are headache and injection reactions e.g. redness, swelling, irritation, rash, itching, numbness, pain, discomfort, stinging, bruising and bleeding. Normally these reactions are mild to moderate, reversible and occur in the first week after treatment. There is also a small possibility of slight drooping of the eyelid or visual problems. • Very rarely, [Botulinum Toxin Type A] may result in muscle weakness away from the site of injection. Other side effects are listed in the Patient Information Leaflet [please ask if you have not been given this]. • If symptoms last for more than one week or you are concerned about any symptoms you should report them to your practitioner as soon as possible. Seek urgent medical help if you have difficulties breathing, swallowing, speaking or if your face swells up. • [Botulinum Toxin Type A] may cause temporary blurred vision or muscle weakness. If affected, you should not drive or use machinery. • [Botulinum Toxin Type A] contains a very small amount of albumin which comes from human blood. It is very unlikely that this could pass on an infection, but it cannot be entirely ruled out. The practice of medicine and surgery is not an exact science and therefore that no guarantee can be given as to the results of the treatment referred to in this document.

I consent

I do not consent

Can I wear makeup to my appointment? *

It is better to attend your appointment with nothing on your skin. If you wear makeup, we will cleanse it off anyway. Natural skin oil and sweat can mix with your makeup and make it difficult to assess your skin properly during the appointment. Dr. Madden needs to clearly see your skin’s natural state, which helps determine how much or little toxin should be used for the desired effect. Dr. Madden will clean your skin with rubbing alcohol before your injections.

YES - I understand it is preferable to wear no makeup to my appointment

I understand the anti wrinkle injections are for the upper face only- "crow's feet, frown lines and 11s" *

YES - I understand

I accept and understand that the goal of this treatment is improvement, not perfection, and that there is no guarantee that the anticipated results will be achieved. *

YES - I understand

When completing the medical history questionnaire, I have answered the questions fully and to the best of my ability. I have also given further details relating to my medical history when asked. *

YES

I agree that after treatment I will follow the post-treatment advice given to me by my practitioner. *

YES

Are you pregnant? *

YES

NO

I agree that I am responsible for paying for my treatment in full on the day of treatment and I agree to do so. I understand that my practitioner can obtain any money outstanding after treatment by taking me to the small claims courts. *

YES

I understand that no refunds are available after treatment has been given. *

YES

I understand that it is a requirement for insurance purposes that photos are taken and kept in your medical records for at least 6 months. I consent to have clinical photographs of the areas I am having treated to monitor treatment effects, as desired or recommended by my practitioner. My practitioner has explained to me that these photographs are kept confidential. *

YES

I agree with the details outlined in this form and request to have Botulinum Toxin Type A treatment for cosmetic reasons and authorise the practitioner named above to treat me *

YES