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Medical Questionnaire and Consent Form for Botulinum Toxin (BOTOX) & Dermal Fillers

Client Information - please read carefully prior to treatment:

  • Facial aesthetic proceures are not avaiable to those under the age of 18;
  • Treatment cannot be carried out on pregnant or breatfeeding mothers;
  • Botox Treatment cannot be carried out on client with neuromuscular disorders such as Multiple Sclerosis, Myasthenia Gravis, Belis Palsy;
  • The practitioner has a right to decline treatment if it is not in the client's best interest to perform it;
  • The client should not present with unreaslist expectations of results which cannot be achieved by non-surgical means;
  • The practitioner has the right to decline treatment to clients with suspected BOD (Body Dysmorphia disorder);
  • It is the client's responsibility to follow post-op instructions to the best of his/hers ability in order to obtain the best results possible;

Risks and Possible Complications 

Possible Risks, Complications & Side Effects to Botox:

  • Hypersensitivity, Allergic response, Anaphylactic reaction (rare but can occur)
  • Asymmetry of facial expressions
  • Muscle weakness, twitching, Headaches
  • Bruising/swelling/skin redness
  • Stinging/burning
  • Drooping of the eyelid or eyebrow (ptosis)/local muscle weakness, double vision, dry/teary eyes
  • Hives, feeling faint, nausea or flu like symptoms, tiredness
  • Swelling of the face or throat, dry mouth, difficulty swallowing
  • Infection at treatment site
  • Period to take effect, further treatment needed, remaining muscle movement

Possible Risks, Complications & Side Effects to Dermal Fillers: 

  • Hypersensitivity, Allergic response, Anaphylactic reaction (rare but can occur)
  • Formation of nodules (lumps) around the treated area
  • Slight visibility/palpability of the product under the skin
  • Persistent bruising which may last up to several weeks
  • Infection/abscess formation following treatment, eruption of cold sores
  • Small/Rare possibility of filler being injected into a blood vessel which could lead to blockage of the blood flow to the area supplied by the blood vessel causing skin soreness, coldness, numbing and discoloration. Please contact the clinic as soon as possible in this instance.
  • Perfect symmetry may not be achievable.
  • Limited or non-response to treatment
  • Extremely rare risk of blindness if filler is injected into certain anatomical sites, such as the Glabella, Nasolabial folds and the Nose.

General Complications: 

  • Stinging/tingling/burning/bruising/swelling
  • Injection site bleeding/skin redness around treatment area

Please Note.

  • Due to the subjective nature of the treatment it is not possible to guarantee results
  • Longevity of treatment results may vary between individuals.
  • Patients can react differently to the same treatment
  • List of possible risks and complications is not exhaustive.

I have read and understood the side effects and possible complications related to my treatment.

Today's Date: August 26, 2019

I Agree

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Medical History

Please respond with YES or NO to the below questions (in case of YES please provide details):


Current Health Problems? *

Past medical history? *

Previous Medical/Aesthetic Surgery (including dermal filler, Botox, skincare programmes): *

Muscle disorders? *

Thrombosis, bleeding disorder, bruising? *

Skin conditions, pigmentation, scarring? *

Cold sores? *

Referred/Under the care of psychologist, psychiatrist or counselor? *

Medications (including topical creams): *

Known allergies? Including allergic reactions to latex, dermal fillers, botulinum toxins, anesthesia (including topical): *

Recent sun exposure, use of sunbeds/tanning? *

Pregnant/Breastfeeding? *

Smoker? *

Anything else you think may be relevant?
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Medical History

Please respond with YES or NO to the below questions (in case of YES please provide details):


Current Health Problems? *

Past medical history? *

Previous Medical/Aesthetic Surgery (including dermal filler, Botox, skincare programmes): *

Muscle disorders? *

Thrombosis, bleeding disorder, bruising? *

Skin conditions, pigmentation, scarring? *

Cold sores? *

Referred/Under the care of psychologist, psychiatrist or counselor? *

Medications (including topical creams): *

Known allergies? Including allergic reactions to latex, dermal fillers, botulinum toxins, anesthesia (including topical): *

Recent sun exposure, use of sunbeds/tanning? *

Pregnant/Breastfeeding? *

Smoker? *

Anything else you think may be relevant?
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Medical History

Please respond with YES or NO to the below questions (in case of YES please provide details):


Current Health Problems? *

Past medical history? *

Previous Medical/Aesthetic Surgery (including dermal filler, Botox, skincare programmes): *

Muscle disorders? *

Thrombosis, bleeding disorder, bruising? *

Skin conditions, pigmentation, scarring? *

Cold sores? *

Referred/Under the care of psychologist, psychiatrist or counselor? *

Medications (including topical creams): *

Known allergies? Including allergic reactions to latex, dermal fillers, botulinum toxins, anesthesia (including topical): *

Recent sun exposure, use of sunbeds/tanning? *

Pregnant/Breastfeeding? *

Smoker? *

Anything else you think may be relevant?
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Medical History

Please respond with YES or NO to the below questions (in case of YES please provide details):


Current Health Problems? *

Past medical history? *

Previous Medical/Aesthetic Surgery (including dermal filler, Botox, skincare programmes): *

Muscle disorders? *

Thrombosis, bleeding disorder, bruising? *

Skin conditions, pigmentation, scarring? *

Cold sores? *

Referred/Under the care of psychologist, psychiatrist or counselor? *

Medications (including topical creams): *

Known allergies? Including allergic reactions to latex, dermal fillers, botulinum toxins, anesthesia (including topical): *

Recent sun exposure, use of sunbeds/tanning? *

Pregnant/Breastfeeding? *

Smoker? *

Anything else you think may be relevant?
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Medical History

Please respond with YES or NO to the below questions (in case of YES please provide details):


Current Health Problems? *

Past medical history? *

Previous Medical/Aesthetic Surgery (including dermal filler, Botox, skincare programmes): *

Muscle disorders? *

Thrombosis, bleeding disorder, bruising? *

Skin conditions, pigmentation, scarring? *

Cold sores? *

Referred/Under the care of psychologist, psychiatrist or counselor? *

Medications (including topical creams): *

Known allergies? Including allergic reactions to latex, dermal fillers, botulinum toxins, anesthesia (including topical): *

Recent sun exposure, use of sunbeds/tanning? *

Pregnant/Breastfeeding? *

Smoker? *

Anything else you think may be relevant?
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Medical History

Please respond with YES or NO to the below questions (in case of YES please provide details):


Current Health Problems? *

Past medical history? *

Previous Medical/Aesthetic Surgery (including dermal filler, Botox, skincare programmes): *

Muscle disorders? *

Thrombosis, bleeding disorder, bruising? *

Skin conditions, pigmentation, scarring? *

Cold sores? *

Referred/Under the care of psychologist, psychiatrist or counselor? *

Medications (including topical creams): *

Known allergies? Including allergic reactions to latex, dermal fillers, botulinum toxins, anesthesia (including topical): *

Recent sun exposure, use of sunbeds/tanning? *

Pregnant/Breastfeeding? *

Smoker? *

Anything else you think may be relevant?
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Medical History

Please respond with YES or NO to the below questions (in case of YES please provide details):


Current Health Problems? *

Past medical history? *

Previous Medical/Aesthetic Surgery (including dermal filler, Botox, skincare programmes): *

Muscle disorders? *

Thrombosis, bleeding disorder, bruising? *

Skin conditions, pigmentation, scarring? *

Cold sores? *

Referred/Under the care of psychologist, psychiatrist or counselor? *

Medications (including topical creams): *

Known allergies? Including allergic reactions to latex, dermal fillers, botulinum toxins, anesthesia (including topical): *

Recent sun exposure, use of sunbeds/tanning? *

Pregnant/Breastfeeding? *

Smoker? *

Anything else you think may be relevant?
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Medical History

Please respond with YES or NO to the below questions (in case of YES please provide details):


Current Health Problems? *

Past medical history? *

Previous Medical/Aesthetic Surgery (including dermal filler, Botox, skincare programmes): *

Muscle disorders? *

Thrombosis, bleeding disorder, bruising? *

Skin conditions, pigmentation, scarring? *

Cold sores? *

Referred/Under the care of psychologist, psychiatrist or counselor? *

Medications (including topical creams): *

Known allergies? Including allergic reactions to latex, dermal fillers, botulinum toxins, anesthesia (including topical): *

Recent sun exposure, use of sunbeds/tanning? *

Pregnant/Breastfeeding? *

Smoker? *

Anything else you think may be relevant?
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Medical History

Please respond with YES or NO to the below questions (in case of YES please provide details):


Current Health Problems? *

Past medical history? *

Previous Medical/Aesthetic Surgery (including dermal filler, Botox, skincare programmes): *

Muscle disorders? *

Thrombosis, bleeding disorder, bruising? *

Skin conditions, pigmentation, scarring? *

Cold sores? *

Referred/Under the care of psychologist, psychiatrist or counselor? *

Medications (including topical creams): *

Known allergies? Including allergic reactions to latex, dermal fillers, botulinum toxins, anesthesia (including topical): *

Recent sun exposure, use of sunbeds/tanning? *

Pregnant/Breastfeeding? *

Smoker? *

Anything else you think may be relevant?
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Medical History

Please respond with YES or NO to the below questions (in case of YES please provide details):


Current Health Problems? *

Past medical history? *

Previous Medical/Aesthetic Surgery (including dermal filler, Botox, skincare programmes): *

Muscle disorders? *

Thrombosis, bleeding disorder, bruising? *

Skin conditions, pigmentation, scarring? *

Cold sores? *

Referred/Under the care of psychologist, psychiatrist or counselor? *

Medications (including topical creams): *

Known allergies? Including allergic reactions to latex, dermal fillers, botulinum toxins, anesthesia (including topical): *

Recent sun exposure, use of sunbeds/tanning? *

Pregnant/Breastfeeding? *

Smoker? *

Anything else you think may be relevant?
Parent or Guardian's Email Address

Email*

Confirm Email*
Social Media
I give consent for identifiable photos to be used across social media networks:*
No
Yes
I give consent for NON-identifiable photos to be used across social media networks:*
No
Yes
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Medical History

Please respond with YES or NO to the below questions (in case of YES please provide details):


Current Health Problems? *

Past medical history? *

Previous Medical/Aesthetic Surgery (including dermal filler, Botox, skincare programmes): *

Muscle disorders? *

Thrombosis, bleeding disorder, bruising? *

Skin conditions, pigmentation, scarring? *

Cold sores? *

Referred/Under the care of psychologist, psychiatrist or counselor? *

Medications (including topical creams): *

Known allergies? Including allergic reactions to latex, dermal fillers, botulinum toxins, anesthesia (including topical): *

Recent sun exposure, use of sunbeds/tanning? *

Pregnant/Breastfeeding? *

Smoker? *

Anything else you think may be relevant?
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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