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BOTOX Consent


Healthspan Medical PTY LTD


CONSENT FORM – Botulinum Toxin


I confirm I have been informed that:

Botulinum Toxin is approved for the treatment of glabellar lines (frown lines between the
eyebrows), forehead lines and lateral canthal lines (crow’s feet lines) and is injected into the skin to
help correct wrinkles. Possible things that could happen when, or after, the product is used, if they
occur, usually appear within the first few days following injection, and are usually temporary and
mild to moderate in severity. As with any prescription medicines, Botulinum Toxin can cause side
effects and your doctor will advise you about these in more detail. The most common side effects
associated with the use of Botulinum Toxin are headaches, eyelid ptosis (drooping of upper eyelid),
eyelid oedema, brow ptosis, skin tightness, facial pain and paresis, and muscle weakness to
surrounding muscles. As with any injection, pain, burning, stinging, swelling, redness and/or
bleeding/bruising may occur. Patients treated with recommended doses of Botulinum Toxin may
experience complete muscle weakness.

If you are worried about any side effect you think you may be experiencing, or the duration thereof,
contact your doctor as soon as possible to discuss this and to obtain medical advice or treatment if
needed. Side effects possibly related to the spread of toxin distant from the site of administration
have been reported very rarely with botulinum toxin (e.g. exaggerated weakness in other muscles in
your body not near to where the injection was given, difficulty in swallowing or pneumonia due to
unwanted food or liquid in the airways, which can be fatal). A severe allergic reaction may occur very
rarely after the injection of Botulinum Toxin. If you experience any of the above, contact your
medical doctor immediately to obtain medical advice and/or attention.

Injection of Botulinum Toxin is not recommended in patients with a history of dysphagia (difficulty in
swallowing). Contact your medical doctor and seek medical attention immediately if you develop
breathing, swallowing, or speech difficulty.

Too frequent or excessive dosing of Botulinum Toxin 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 aesthetic effects of Botulinum Toxin 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 make
up for 12 hours. Please avoid sun exposure, UV light, freezing temperatures and saunas for 2 weeks
after treatment.

(Before treatment)

One week prior to your Botulinum Toxin treatment, we advise you to avoid using alcohol, garlic,
and/or aspirin, or any other non-steroidal anti-inflammatory drugs for pain, swelling and/or fever,
such as medicines containing diclofenac, mefenamic acid, indomethacin or ibuprofen - ask your
doctor or pharmacist whether your medication includes any of these ingredients. Following these
instructions will reduce the risk of bruising or bleeding at the point of injection.
If this is your first visit, you will need to provide your medical doctor with information on your
medical history and any current problems, as well as details of any allergies you have or medications
you are taking. There is no need for an allergy test, unless your medical practitioner feels it’s

(After treatment)
The aesthetic 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. Results of your treatment may take up to 14 days to take
full effect.
After treatment:
• For 4 hours - do not lie down or do “strenuous” exercise and similar activities, nor should
you do anything that increases the blood flow to the injection area
• For 12 hours - avoid extreme facial expressions, alcohol consumption, and applying make-up
• For 24 hours - do not rub or massage the treated areas as this could influence the effect of
the product
• For 2 weeks - avoid direct sun exposure, UV light, freezing temperatures and saunas
Please consult with your medical doctor if further treatment is required.

Treatment may be refused by your HCP if it is not considered in your best interest to proceed.

I understand that I can withdraw this consent at any stage prior to the commencement of treatment,
and that any subsequent decision relating to refusal of continued treatment, including top-ups, will
have an effect on the achievement of the treatment. I therefore consent to receiving the described
treatment by my medical doctor.

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