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Botox Disclaimer Form

Pregnant
Breastfeeding
Do you Smoke?
Do you suffer from Cold Sores?
Have you ever had Hyaluronidase (Hyluron) for the removal of Dermal Fillers?
Jaundice (Hepatitis) or other liver disease?
Rheumatic Fever or Chorea (St Vitus Dance)?
Asthma, Eczema or other allergic disease?
Have you ever had an Anaphylaxis reaction? Do you carry an Epi Pen?
Any heart conditions such as Angina, Murmur and valve problems?
A stroke or blood pressure problems? A valve or joint replacement?
An allergic reaction to substances or drugs such as; foods, latex, steroids or antibiotics?
Have you ever had a reaction to either Botulinum Toxin or Dermal Fillers?
Steroids within the last two years or any recent vaccinations?
A valve replacement, joint replacement or implant?
An operation or surgical treatment or a general anaesthetic or sedation?
A period as an in-patient at a hospital?
Do you currently take any pills or medication?
Are you using an inhaler or any other form of medication?
Are you using any complementary supplements i.e. St John Wort?
Do you suffer from fainting attacks?
Do you bleed or bruise easily?
Do you or any family members have diabetes or epilepsy?

Side Effects & Non Guarantee Disclaimer

Side effects of Botox include:

allergic reactions,
rash,
itching,
headache,
neck or back pain,
muscle stiffness,
difficulty swallowing,
shortness of breath,
nausea,
diarrhea,
stomach pain,
loss of appetite,
muscle weakness,
injection site reactions including
bruising,
bleeding,
pain,
redness,
swelling, or
infection,
fever,
cough,
sore throat,
runny nose,
flu symptoms,
cold symptoms
respiratory infections,
dizziness,
drowsiness,
tired feeling,
anxiety,
dry mouth,
ringing in your ears,
increased sweating in areas other than the underarms,
urinary tract infections,
burning/painful urination, and difficulty urinating.

There are many variable conditions in addition to stated risk and potential complications which may have an influence on the results of Botulinium Toxin Injections. Even though complications and risks occur infrequently, the risks cited are those that are particularly associated with Botox Injections.

Other complications and risks can occur but are more uncommon than those previously cited. Should complications occur, additional treatment may be necessary. The practice of medical or aesthetic treatments is not an exact science, although good results are always expected, there is no guarantee or warranty, express or implied, on the results that may be obtained.

Pre-Treatment Advice

Paracetamol - Please take paracetamol 1 hour before your treatment.

Medical Consent Form - Please do not forget to complete your medical consent form prior to your treatment. YOU CANNOT BE TREATED UNLESS THIS IS COMPLETE.

Pre-treatment Tips:
In order to reduce the amount of bruising and/or swelling from the injection sites, please follow the instructions below.

- In order to reduce the amount of bruising and/or swelling from the injection sites, please follow the instructions below.

- Avoid blood thinning over-the-counter medications such as Aspirin, Motrin, Ibuprofen, and Aleve for 1 week prior. Please consult your physician if you are taking Aspirin for medical reasons!

- Avoid supplements including St. Johns Wort, ginko biloba, primrose oil, garlic, ginseng, and Vitamin E for 1 week.

- Avoid topical products such as Tretinoin (Retin-A), Retinols, Retinoids, Glycolic Acid, or any "Anti-Ageing" products for 3 days prior.

- Avoid waxing, bleaching, tweezing, or hair removal cream on the area to be treated for 3 days prior.

- Do not drink alcoholic beverages for 24 hours prior to treatment.

- If you have previously suffered from facial cold sores, there is a risk that the needle punctures could contribute to another eruption of cold sores.

- Do not use botulinium toxin if you are pregnant or breastfeeding, are allergic to any ingredients, or suffer from neurological disorders. Please inform us if you have any questions.

If you have any questions regarding any of the Pre-Treatment advice please kindly send us an email or message us on social media and we will gladly answer any questions.

Please confirm your Full Name and Date below to confirm the above details are correct:

By giving your name, DOB and submitting the form below you agree that you have answered all questions truthfully and disclosed any other relevant information. Failure to disclose correct information can be considered an offence in court.

Thank you, the form has been submitted.

© 2023 by Helenka 

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