ANTI-WRINKLE INJECTIONS CONSENT FORM

Client name: ______________________________________________________________________

Client address: ______________________________________________Town/City: _____________

Post code:______________

Client contact details: Phone: ___________________________ Email: ________________________

D.O.B. _______/___________/____________ Gender: male/female (please delete one)

MARKETING
Each week we would like to contact you with special offers, related products and relevant services from
aUK. If you consent for this purpose, please tick your preferences:
SMS ▢ / Email ▢

Important statement - please read:

Photographs taken shall be part of the medical record and used for documentation of response to
treatment. With explicit permission these photographs may also be used for educational purposes or for
client information.

>> Yes I confirm – please sign here: _____________________________________________

As part of the marketing activity (digital and/or print) we would like to use anonymously before & after
photos of your treatment for use to promote this treatment.

>> Yes I confirm – please sign here: _____________________________________________

Introduction to Anti-Wrinkle Injections

I confirm I have seen a prescribing nurse for a medical health check prior to today's treatment

>> Please sign here: _______________________________ Date: ______/________/__________

1. Botulinum A Toxin injection take approx. 2 weeks to take full effect - they are NOT IMMEDIATE
2. Injection of Botulinum A Toxins into the small muscles between the brows causes those specific
muscles to halt their function (be paralyzed), thereby improving the appearance of the wrinkles
3. This paralysis is temporary and re-injection is necessary within three to four months

I understand that I will be injected with Botulinum A Toxin in the area of one, or more from the list
below to paralyze these muscles temporarily

• Glabella, Corrugator Supercilii and Procerus muscles - Frown lines

• Frontalis Muscle - Forehead
• Lateral Orbital Lines: Orbicularis Oculi and Procerus Muscles - Crow’s Feet side of your eyes
 • Bunny Lines (Transverse nasal) - around your nose
• Perioral Lines (Smoker’s Lines): Orbicularis Oris Muscle
• Marionette Lines: Depressor Anguli Oris and/or Trangularis Muscles
• Mentalis Dysfunction (Chin “Dents”): Mentalis Muscle
• Vertical Platysma Bands: Platysma Muscle
• Brow Lift
• Hyperhidrosis (excessive sweating): blocking the release of acetylcholine. (Acetylcholine is the
body’s chemical which stimulates the sweat glands)
• Armpits: Axillary

I understand the goal is to decrease the wrinkles in the treated areas, or reduce sweating in the relevant
area listed above. Please sign to acknowledge you understand and consent to continuing with the
procedure.

>> Client: Yes I understand the treatment please sign here: _______________________________

The possible side effects of Botulinum A Toxin include but are not limited to:

RISKS: A risk of swelling, rash, headache, local numbness, pain at the injection site, bruising, respiratory
problems, and allergic reaction.

INFECTION: Infections can occur which in most cases are easily treatable bit in rare cases a permanent
scarring in the area can occur.

Most people have slightly swollen pinkish bumps where the injections went in, for a couple of hours or
even several days. Although many people with chronic headaches or migraines often get relief from
Botulinum A Toxin, a small percent of patients get headaches following treatment with Botulinum A
Toxin, for the first day. In a very small percentage of patients these headaches can persist for several
days or weeks. Local numbness, rash, pain at the injection site, flu like symptoms with mild fever, back
pain. Respiratory problems such as bronchitis or sinusitis, nausea, dizziness, and tightness or irritation of
the skin. Bruising is possible anytime you inject a needle into the skin. This bruising can last for several
hours, days, weeks, months and in rare cases the effect of bruising could be permanent.

While local weakness of the injected muscles is representative of the expected pharmacological action
Botulinum A Toxin, weakness of adjacent muscles may occur as a result of the spread of the toxin.

TREATMENTS: More than one injection may be needed to achieve a satisfactory result.

Another risk when injecting Botulinum A Toxin around the eyes included corneal exposure because
people may not be able to blink the eyelids as often as they should to protect the eye. This inability to
protect the eye has been associated with damage to the eye as impaired vision, or double vision, which
is usually temporary. This reduced blinking has been associated with corneal ulcerations. There are
medications that can help lift the eyelid, however, if the drooping is too great the eye drops are not that
effective. These side effects can last for several weeks or longer. This occurs in 2-5 percent of clients.

>> Client: Yes I understand the side-effects - please sign here: _______________________________
As Botulinum A Toxin injections are not an exact science, there might be an uneven appearance of the
face with some muscles more affected by the Botulinum A Toxin than others. In most cases this uneven
appearance can be corrected by injecting Botulinum A Toxin in the same or nearby muscles. However in
some cases this uneven appearance can persist for several weeks or months.

This list is not inclusive of all possible risks associated with Botulinum A Toxin as there are both known
and unknown side effects associated with any medication or procedure.

• Botulinum A Toxin should not be administered to a pregnant or breastfeeding woman

• Additionally, the number of units injected is an estimate of the amount of Botulinum A Toxin
required to paralyze the muscles. I understand there is no guarantee of results of any treatment.

I understand and agree that all services rendered to me are charged directly to me and that I am
personally responsible for payment. I further agree in the event of non-payment, to bear the cost of
collection, and/or court cost and reasonable legal fees, should this be required.

I acknowledge I fully understand all that has been explained to me.

>> Client: yes I understand & agree, please sign here: _______________________________

MEDICAL HISTORY & CURRENT MEDICAL CONDITIONS

Please check any health conditions which you have ever had previously or are now experiencing.
Are you currently in good health? YES/ NO
If NO, for what reason?__________________________________________
Do you carry a warning card, an EpiPen, or have you ever had an anaphylaxis reaction? YES/NO
If YES, please tell us more:__________________________________________
Are you currently under a specialist, hospital or doctor’s care? YES / NO
If YES, for what reason? Please type:_____________________________________________
Do you use ANY medication, herbal/natural supplements or topical creams on a regular basis? YES /NO
If YES please list:______________________________________________________
Do you have ANY allergies to medications, food, latex, or other substances? YES/ NO
If YES please list:____________________________________________________
Have you had any cold sore breakouts (oral herpes) in the past year? YES/NO
Do you have a history of Keloid Scarring? YES/NO
Any blood-borne diseases? YES/NO
If YES please list:____________________________________________________
Angina, murmur, valve or other heart conditions? YES/NO
If YES please list:____________________________________________________
A stroke or any other blood pressure problems? YES/NO
If YES please list:____________________________________________________
Any neurological conditions such as epilepsy, Bell’s Palsy, MS, Chorea or Myasthenia Gravis? YES/NO
If YES please list:____________________________________________________
Any recent vaccinations, cortisone injections or steroids? YES/NO
If YES please list:____________________________________________________
Replacements, implants, operations, X-rays recently? YES/NO
If YES please list:____________________________________________________
Any other diseases, illnesses or treatments? YES/NO
If YES please list:____________________________________________________
Do you suffer with Acne, or have you taken medication for Acne in the past 6 months? YES/NO
Have you ever had cancer? YES/NO
If YES please tell us what type:______________________________
Do you have ANY current or chronic medical illness, including: Myasthenia Gravis, Amyotrophic Lateral
Sclerosis or any other Neuromuscular disorders? YES/ NO
If YES please list:_______________________________________________________
Do you have an autoimmune disease? (e.g. Crohn's disease) YES/NO
If YES please list: ______________________________
Jaundice, Hepatitis, Liver or Kidney disease? YES / NO
If YES please tell us which:__________________________
Have you ever had eyelid or facial surgery? YES NO
If YES, when and in which area(s)?________________________________________
Asthma, Eczema or other allergic disease?
If YES, when and in which area(s)?________________________________________
AIDS/HIV? YES/NO
If YES, please share details______________________________________________
Deep skin peeling? Yes/NO
If YES, when and in which area(s)?________________________________________
Have you previously received BOTOX/ DERMAL FILLER injections? YES / NO
When: _______________________________________________
Area treated:__________________________________________
Any previous adverse reactions:___________________________

For Women only:

• Are you, or could you be pregnant? YES/ NO
• Are you going through IVF? YES / NO
• Are you breastfeeding? YES/ NO

Current Medical Status

1. Taking medicines, pills, tablets, ointments or inhalers? YES / NO

a. If YES please tell us which:__________________________
2. Use therapies or supplements such as St. John’s Wort? YES / NO
a. If YES please tell us which:__________________________
3. Do you bruise or bleed easily? YES / NO
4. Any circulative problems or varicose veins? YES / NO
5. Any endocrine disorders? (diabetes, thyroid) YES / NO
a. If YES please tell us which:__________________________
6. Do you follow a healthy diet? YES / NO
7. Do you take regular exercise? YES / NO
8. Fluid intake – please tick which apply to you: Water ▢ Alcohol ▢ Tea ▢ Coffee ▢ Herbal tea ▢
9. Have you had electrical facial treatments before? YES / NO
By signing below I acknowledge that I have read the foregoing informed consent and agree to the
treatment with its associated risks.

>>Client: Yes I consent – please sign here: _____________________________________________

BOTULINUM RESULTS

I am aware that full correction is important and that follow-up enhancement treatments will be needed
to maintain the full effects. I am aware that the duration of treatment is dependent on many factors
including but not limited to: age, sex, tissue conditions, my general health, my lifestyle conditions, and
sun exposure. The correction, depending on these factors, may last upto 3 months and in some cases
shorter and some cases longer.

I hereby voluntarily consent to treatment. The procedure(s) has been explained to me. I have read
The consent form and understand it. My questions have been answered satisfactorily. I accept the risks
and complication of the procedure. I certify that if any changes occur in my medical history, I will notify
Beyoutiful Brows. I have read this informed consent and certify that I understand its contents in full. I
have had enough time to consider the information from my practitioner/trainee and feel that I am
sufficiently advised to consent to this procedure. I hereby give my consent to this procedure and have
been asked to sing this form after my discussion with the Beyoutiful Brows practitioner/trainee.

I will follow all aftercare instructions as it is crucial I do so for healing.

I hereby release the Beyoutiful Brows practitioner/trainee, the person(s) injecting the Botulinum A Toxin
and the Beyoutiful Brows facility from liability associated with this procedure.

Client signature: ___________________________________

Client first name (PLEASE PRINT): ____________________________________________________
Client surname (PLEASE PRINT):______________________________________________________
Client treatment(s): ____________________________________________________

PRACTITIONER/TRAINEE USE ONLY

I confirm that I have fully informed the patient about the risks and benefits of treatment with Botulinum

Toxin and I believe they understand all the information given.

They have also been informed of alternative treatment for their presenting complaint.

Practitioner/trainee Signature: ____________________________________________________

Practitioner/trainee Name: _______________________________________________________
Date: __________/______________/______________
Practitioner/Trainee only: Procedure sheet

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