Botulinum Toxin

Full Name:
Date of birth:
Address:
Postcode:
Mobile number:
Email address:
GP surgery:
Emergency number:

Do you have any medical conditions
YesNo

Are you taking any medicines?
YesNo

Do you have any Drug allergies?
YesNo

Are you pregnant/breast feeding/undergoing IVF?
YesNo

Have you had dental work in the past?
YesNo

What is your occupation?

Do you exercise regularly?
YesNo

Have you had any surgery?
YesNo

Have you had any aesthetic surgery?
YesNo
If yes please specify what e.g. lifting, liposuction, eyelid, nose, jaw, hair transplant etc.
And when:
≤ 1 month≤ 3 months≤ 6 months≤ 1 year≥ 1 year

Have you already undergone aesthetic procedure?
YesNo
If yes please specify:
botulinum toxindermal fillerskin peeldermabrationlaseror any other
And when:
≤ 1 month≤ 3 months≤ 6 months≤ 1 year≥ 1 year

Did these previous procedures cause any undesirable reactions?
YesNo

Consent

Consent for Injectable Treatment:
-I have discussed my medical history fully with my practitioner, including side effects of complications of my treatment relating to these conditions.
-The use of, and indications, for the products I will be treated with have been explained to me by my practitioner.
-I have discussed realistic expectations with my practitioner.
-I understand that results cannot be guaranteed and my practitioner will use their best judgement.
-I have had the opportunity to have my questions answered.
-I have discussed aftercare instructions with my practitioner to gain optimal results from my treatment.
-I am aware that the duration of effect of treatment can be shorter or longer than stated in an individual patient.
-I have been specifically informed of the following common injection related reactions: redness, swelling, pain, itching, bruising and tenderness at the treatment site. These reactions are mild to moderate and typically resolve within a few days.
-Repeat treatment will hep to maintain the desired correction in the long term.

Consent for Botulinum Toxin Treatment
-I have been advised by my practitioner of the expected outcomes and risks associated with this treatment.
-Potential side effects include: feeling of heaviness in the forehead, change in eyebrow position, headache, eyelid swelling, eyelid droop, blurred vision, facial asymmetry, under or over treatment effect, double vision and infection.
-Rare risks including; allergy (including anaphylaxis), flu-like symptoms, dry mouth, muscle twitching, muscle cramps, excessive muscle weakness and swallowing difficulty.
-My practitioner has informed me that the effect of botulinum toxin treatment can last approximately 3 months on average.

Patient Statement
- I am aware that the treatment performed and my personal details, any images taken and clinical notes will be used as part of the practitioners’ confidential portfolio.
- My practitioner has advised me of the amount if product required and the cost of the treatment, which I have already paid, or will pay immediately after treatment for any additional treatment received.
- I certify that I have read the above information fully and understand the complications that could occur.
- I have had sufficient time for discussion with my practitioner and agree to treatment today.
- The information that I have provided is to the best to my knowledge correct.
- I confirm the medical questionnaire is up to date and correct at the time of treatment.
- I have expressed my thoughts and feelings to the practitioner and consent to treatment for the purpose of restoring and maintaining my health and my psychological wellbeing.

I herby consent to treatment.
YesNo

I have read and agree to Apple Tree Aesthetics terms and conditions.
YesNo