BOTOX CONSENT FORM

BOTOX CONSENT FORM

PATIENT INFORMATION:

First Name

Last Name

Date Of Birth

Phone/Mobile

City

Next Of Kin

Kins Contact Number (Phone/Mobile)

MEDICAL HISTORY

Have you received botulinum toxin injections (e.g., Botox, Dysport) in the past 6 months?

Yes

Do you have any neurological or muscular disorders (e.g. ALS)?

Yes

If Yes, please specify:

Are you currently taking any medications that affect bleeding or muscle function (e.g., blood thinners, muscle relaxants)?

Yes

If Yes, please specify:

Do you have any allergies, especially to botulinum toxin products or human albumin?

Yes

If Yes, please specify:

Are you currently pregnant, trying to conceive, or breastfeeding?

Yes

If Yes, please specify:

Do you have any other medical conditions?

Yes

If Yes, please specify:

Procedure Description:

I understand that I am receiving botulinum toxin injections (commonly known as Botox) for cosmetic purposes. This is a non-surgical procedure used to temporarily reduce the appearance of fine lines and wrinkles by relaxing targeted facial muscles.

During the procedure, a purified form of botulinum toxin is injected in small amounts into specific muscles using a fine needle. The treatment works by blocking nerve signals to the muscles, preventing them from contracting and thereby softening the appearance of dynamic wrinkles such as frown lines, forehead lines, and crow’s feet.

The procedure typically takes a short amount of time and may cause minimal discomfort. No anesthesia is usually required, although a topical numbing agent may be applied if necessary.

I understand that results are not immediate and typically begin to appear within a few days, with full results visible within 7–14 days. The effects are temporary and generally last between 3 to 6 months, after which repeat treatments may be required to maintain results.

Benefits and Risks:

I have been informed that the potential benefits of Botox treatment may include:

Reduction in the appearance of fine lines and wrinkles
Smoother, more youthful-looking skin
Prevention of deeper wrinkle formation with continued treatment
Quick procedure with minimal downtime
Non-surgical alternative to facial rejuvenation

I understand that there are potential risks and side effects associated with Botox treatment, including:

Mild discomfort, redness, or swelling at the injection site
Temporary bruising or tenderness
Headache or mild flu-like symptoms (rare)
Temporary drooping of the eyelid or eyebrow (ptosis)
Asymmetry or uneven results
Dry eyes or excessive tearing (depending on treatment area)
Difficulty with certain facial expressions temporarily

I understand that serious complications are uncommon but may occur in rare cases.

Aftercare:

I agree to follow the post-treatment instructions provided by the clinician to ensure the best possible results and minimize any risks. I understand that failure to adhere to these instructions may increase the likelihood of complications.

Consent for Treatment:

I hereby consent to undergo a Botox treatment. I acknowledge that the clinician has explained the procedure, its benefits, and potential risks to me. I have had the opportunity to ask questions, and all of my concerns have been addressed to my satisfaction. I understand that the results of a Botox treatment can vary, and multiple sessions may be required for optimal results.

Release of Liability:

I release The Abram, its employees, and representatives from any liability associated with the Botox treatment, except for cases of negligence or intentional misconduct.

Human Error Acknowledgment:

I understand that aesthetic treatments are performed by qualified clinicians using professional equipment and established protocols. However, I acknowledge that, as with any procedure involving human involvement, there is a possibility of unintended outcomes due to human or technical error. By signing this consent, I accept this inherent possibility and agree that The Abram and its staff shall not be held liable for minor or unintentional errors occurring during the course of treatment, provided that reasonable care and professional standards are followed.

Photographs and records:

I understand that videos and photos will be taken for medical documentation purposes and will be used only for treatment comparisons and tracking progress milestones.

Client's Initial

Receptionist's Initial

Technician's Initial

I agree that all the above information is true and accurate to the best of my knowledge

Client’s signature: