PRE-INSTRUCTIONS:
Patients with blood diseases are contradicted to undergo BOTOX injection.
Patients must stop the following 3 days prior to the procedure:
Aspirin, brufen, sabofen, multivitamins, vit. E & green tea.
SIDE EFFECTS:
Pain or burning sensation
Minimal swelling for 1 to 2 days
Possible bruise for 2 to 14 days
Redness
Possible peeling and pigmentations
Diabetic patient may experience delayed wound healing on the punctured sites
Risk for infections due to multiple punctured sites so Fucidin and Bactroban
ointment or cream must be applied 3x a day for 5 to 10 days post BOTOX injection.
There is no risk of allergic reaction but may develop allergy due to local anesthesia.
Visible result will not be immediate
POST INSTRUCTION:
You can apply makeup once the wound had healed usually 5 to 10 days. If you want to
apply earlier, make sure to use new sponges or brushes.
I certified that I have read and understand the contents of this form and do realize the
side effects and limitations involved. I hereby authorized my doctor to perform BOTOX
injection and relieve my Doctor of the responsibility of any complications.
I understand and agree that I am financially responsible for the payment I made for
that any amount I paid for the sessions or procedures I booked
it will only be valid up to 3 months from the date I made the payment. I understand that
I need to utilize the sessions or procedures within 3 months period. I agree that my
payment made is non-refundable or non-transferable post this period. In case, I decided
not to continue with the procedure session(s), the clinic may offer another substitute
procedure but is not liable to give the cash refund.
"I agree that healthcare provider(s) involved in my care at this facility will access my
health information through the Health Information Exchange System (NABIDH) in
accordance with the Laws of the United Arab Emirates, Emirate of Dubai Legislation and
Dubai Health Authority Policies ".
I declare that I have read and fully understood all points in this consent and that all of
my questions were answered to my satisfaction and I take the full responsibility of my
decision in this consent.
Patient Name & Signature :
Doctor/Therapist Name & Signature :
Witness Name & Signature :
Parent or Gaurdian Name (if patient is minor) :
Date :
Consent to be photographed and published
I, , consent to be photographed and
published on by
while .
I further authorize that the photographs may be published for any purpose and in any
form.