Botox Injection Consent Form

Patient’s Name:
File No.:
DOB:
Mobile Number:
Visit Date:
Procedure Time:
Doctor Name:

PRE-INSTRUCTIONS:
  • Patients with blood diseases are contraindicated to undergo BOTOX injection.
  • Patients must stop the following 3 days prior to the procedure:
    • Aspirin, brufen, sabofen, multivitamins, vitamin 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 patients may experience delayed wound healing on the punctured sites
  • Risk of infection due to multiple punctured sites; Fucidin and Bactroban ointment or cream must be applied 3x a day for 5 to 10 days post BOTOX injection.
  • No risk of allergic reaction but may develop an allergy due to local anesthesia.
  • Visible results 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 certify that I have read and understand the contents of this form and do realize the side effects and limitations involved. I hereby authorize 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 and that any amount I paid for the sessions or procedures I booked 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 the 3-month period. I agree that my payment made is non-refundable or non-transferable post this period.

"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 full responsibility for my decision in this consent.


Patient Name and Signature:

Doctor Name :
Signature


Therapist/Witness:
Signature and Stamp:
Date

Consent to be photographed and published

I, , consent to be photographed and published on Social media, by while before and after the procedure. I further authorize that the photographs may be published for any purpose and in any form


Patient Name and Signature: