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Botox Consent Form

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Botulinum Toxin Type A is a prescription-only neurotoxin used to temporarily relax specific muscles by blocking nerve signals, thereby smoothing dynamic facial wrinkles and treating certain muscle-related or glandular concerns.

It is commonly used for:

  • Frown lines (glabellar region)

  • Forehead lines

  • Crow’s feet

  • Brow lift or facial slimming (masseter reduction)

  • Gummy smile, chin dimpling, downturned mouth corners

  • Neck bands (platysmal bands / Nefertiti lift)

  • Excessive sweating (axillary hyperhidrosis)

The effects typically begin within 3–5 days and reach peak effect around 10–14 days. Results last approximately 3–4 months, but this may vary based on individual response, treatment area, and dosage.


Contraindications


Botulinum Toxin Type A should not be administered if you:

  • Are pregnant or breastfeeding

  • Are under 18 years of age

  • Have a known allergy to Botulinum Toxin or any of its components (e.g., human albumin)

  • Have a history of neuromuscular disorders (e.g., myasthenia gravis, Eaton-Lambert syndrome, ALS)

  • Have an active infection, rash, or inflammation at the treatment site

  • Are currently unwell or have a cold, flu, or general infection

  • Have recently had a COVID-19 vaccine or plan to have one within 2 weeks (discuss timing with your practitioner)

You must inform your practitioner of all medications, especially antibiotics, muscle relaxants, or blood thinners, as well as any past reactions to botulinum toxin.


Risks and Side Effects


Common temporary side effects include:

  • Redness, swelling, bruising, or tenderness at the injection site

  • Headache or mild flu-like symptoms in the first 24–48 hours

  • A feeling of tightness or heaviness in the treated area

 

Less common risks include:

  • Asymmetry or unexpected muscle weakness

  • Drooping of the eyelid or eyebrow (ptosis)

  • Dry eyes or excessive tearing

  • Smile asymmetry or difficulty with certain facial expressions (e.g. lip movement if mouth treated)

  • Local infection or inflammation

In rare cases, effects may be less than expected or last longer than intended.

Side effects are generally temporary, resolving as the product wears off, but can last several weeks in rare cases.


Aftercare Instructions


To ensure best results and reduce the risk of complications:

  1. Remain upright and avoid lying down for at least 4 hours after treatment.

  2. Do not touch, rub, or massage the treated areas for 24 hours.

  3. Avoid alcohol, strenuous exercise, and heat exposure (sunbeds, saunas) for 24–48 hours.

  4. Avoid facial treatments (e.g., facials, peels, microneedling) for 7–10 days.

  5. Mild bruising can be treated with Arnica gel or covered with mineral makeup.

A review or “top-up” may be offered 2–3 weeks post-treatment, if clinically indicated.


Treatment Expectations


  • Botulinum toxin treatments are not permanent and require regular maintenance every 3–5 months.

  • Results can vary depending on muscle strength, metabolism, lifestyle, and individual response.

  • It may take more than one session to achieve the desired effect.

  • Over time, repeated use can help reduce the severity of lines, but this varies from person to person.


Consent Declaration


By signing this form, I confirm that:

  • I have received a full explanation of Botulinum Toxin Type A treatment, including its purpose, expected effects, potential risks, and aftercare.

  • I understand that this is a prescription-only medicine and is being prescribed and administered by a qualified medical professional.

  • I have disclosed my full medical history, medications, allergies, and relevant health conditions.

  • I understand that results vary, and no guarantees have been made regarding outcome or duration.

  • I have had the opportunity to ask questions, and all have been answered to my satisfaction.

  • I am not pregnant or breastfeeding and understand this treatment is not approved for use during pregnancy.

  • I agree to follow all aftercare instructions provided to me.

  • I voluntarily consent to undergo treatment with Botulinum Toxin Type A as discussed.

 

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