Self Assessment
Choose Consent Form
consent form botox english
File Number:
Consent Form - Botox
Terms and Conditions:
• The list below is list of most common side effects however it does not list each potential side effect.
A. Nausea
B. Headache
C. Bruising
D. Development of antibodies to the BOTOX
E. Symptoms resembling the flu
F. Permanent loss of muscle tone (due to repeated injections)
G. Generalized weakness all over the body
H. Facial asymmetry (causes one side of the face to look different than the other)
I. Under correction or overcorrection
J. Paralysis of nearby muscles which can further cause double vision, droopy eyelid, inability to close eye, difficulty whistling or drinking through a straw.
K. Inability to speak
L. Trouble breathing
M. Double or blured vision
N. Puffiness edema around the eyes
O. Eversion or inversion of the eyelids
• Lightly swollen pinkish bumps at the injection sites for a few hours or even several days.
• Contraindications you should not have Botox if: you are pregnant; nursing; allergic to albumin; have an infection, skin condition, or muscle weakness at the site of the injection; or have Eaton-Lambert syndrome, Lou Gehrig’s disease, or myasthenia gravis
• The effects of Botox become apparent 2-5 days after injection and generally last for 4-6 months.
• Alternatives to the procedures and options that I have volunteered for have been fully explained to me.
• Client experiences may vary.
• Any contraindications will void this treatment
• This treatment cannot be transferred to another person
• Once the injection has been given, refunds are prohibited
• Appointments preferences are based on availability
I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:
• Pre and post treatment instructions have been explained to me
• I have had sufficient time to consider the Cellfina® treatment and had the opportunity to ask questions, and all of my questions have been answered to my satisfaction and understanding
• Must notify the clinician if my medical history changes prior to subsequent treatments
• I consent to clinical photographs being taken of my treated areas for my personal health record only
• My signature below constitutes my acknowledgment and understanding of all this information
Patient Name :
Signature:
Doctor Name :
Signature
Witness Name
Witness Signature
Parent or Guardian (if patient is minor)
Patient Name
Patient Signature
DATE/Time
Parent or Guardian (if patient is minor)
WITNESS
Patient Signature
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