Botox Consent Form

I confirm I have been informed that: Adverse Reactions:

Adverse reactions possibly related to the spread of toxin distant from the site of administration have been reported very rarely with botulinum toxin (e.g muscle weakness, difficulty to swallow or pneumonia due to unwanted food or liquid in the airways). Injection of Botox is not recommended in patients with a history of Dysphagia (difficulty to swallow) and impaired swallowing. In general, adverse reactions occur within the first few days following injection and are temporary. Most adverse events reported were of mild to moderate severity. Diffusion of botulinum toxin (Botox) into nearby muscles is possible when high doses are injected, particularly in the neck area. As expected for any injection procedure, pain/burning/stinging, swelling and/ or bruising may be associated with the injection. Speak to your doctor if you are worried about this.

The chance of having a side effect is described by the following categories: ‣ Common- More that 1 out of 100 persons and less than 1 out of 10 persons ‣ Uncommon- More than 1 out of 1,000 persons and less than 1 out of 100 persons ‣ Common side effects are: Headaches, drooping eye lid, skin redness, localised muscle weakness, face pain

Uncommon side effects are: Infection, anxiety, numbness, dizziness, inflammation of the eyelid, eye pain, visual disturbances, nausea (feeling sick), dry mouth, skin tightness, swelling (face eyelid, around the mouth), sensitivity to light, itching, dry skin, muscle twitching, flu syndrome, lack of strength, fever. The following side effects have been reported rarely since Botox has been marketed: rash, hives, itching, different types of red blotchy skin rash, serious allergic reaction (Swelling, particularly of the face and airways, difficulty breathing), hair loss, loss of eyebrows, noises in the ear and decreased hearing. Allergic reactions, difficulties to swallow, speak or breathe, have been reported rarely when botulinum toxin type A (Botox) has been used for other uses. Visit your doctor immediately if such signs develop after Botox treatment.

If any of the side effects get serious, or if you notice any side effects not listed in this leaflet, please contact Juvea Aesthetics. Botox should only be administrated by medically qualified physicians with appropriate qualifications and expertise in this treatment and having the required equipment.

Too frequent or excessive dosing of Botox may increase the risk of antibodies in the blood which may lead to failure of treatment with botulinum toxin when used for this and other conditions.

The aesthetics effects of Botox last for an average of 3-4 months but will vary depending on the condition of the skin, area treated, amount of product injected, injection technique and lifestyle factors such as sun exposure and smoking.

After treatment, please avoid extreme facial expressions, alcohol consumption and applying makeup for up to 12 hours. Please avoid extreme sun exposure, UV light, freezing temperatures and saunas for 2 weeks after treatment.

I confirm that Dr Uche Aniagwu my treatment practitioner has:

  • - Provided me with sufficient information about the treatment detailed overleaf in order to make an informed decision
  • - Given me the opportunity to ask all remaining questions I may have about the treatment and has answered them to the best of their ability.
  • - Given me the time to consider the treatment detailed overleaf.
  • - Receive the relevant medical history information from me to the best of my knowledge.

I therefore consent to receiving the described treatment by my treating practitioner: