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Anti Wrinkle Injections Consent Form

Please fill out the following form
in order to participate in our activity.

Are you currently in good health?
cardiac pacemakers, implanted defibrillators, implanted neurostimulators
drug pumps
Do you carry a warning card, an EpiPen, or have you ever had an anaphylaxis reaction?
malignant tumor
sensitivity or allergy to latex
haemorrhagic conditions
anticoagulation therapy
heart disorders
Are you currently under a specialist, hospital or doctor’s care
areas of the skin which lack normal sensation
Do you use ANY medication, herbal/natural supplements or topical creams on a regular basis
Do you have ANY allergies to medications, food, latex, or other substances
Have you had any cold sore breakouts (oral herpes) in the past year
Do you have a history of Keloid Scarring
Any blood-borne diseases
A stroke or any other blood pressure problems
Any neurological conditions such as epilepsy, Bell’s Palsy, MS, Chorea or Myasthenia Gravis
Allergic to latex, antibiotics, foods, drugs/substances
Any recent vaccinations, cortisone injections or steroids
Replacements, implants, operations, X-rays recently
Do you suffer with Acne, or have you taken medication for Acne in the past 6 months
Do you have ANY current or chronic medical illness, including: Myasthenia Gravis, Amyotrophic Lateral Sclerosis or any other Neuromuscular disorders
Do you have an autoimmune disease
Jaundice, Hepatitis, Liver or Kidney disease
Have you ever had eyelid or facial surgery
Asthma, Eczema or other allergic disease
Deep skin peeling
Have you previously received BOTOX/ DERMAL FILLER injections
Are you, or could you be pregnant
Are you going through IVF
Are you breastfeeding
Taking medicines, pills, tablets, ointments or inhalers
Use therapies or supplements such as St. John’s Wort?
Do you bruise or bleed easily
Any circulative problems or varicose veins
Any auto-immune disease, including lupus
Any endocrine disorders? (diabetes, thyroid)
Do you follow a healthy diet?
I am aware that full correction is important and that follow-up enhancement treatments will be needed to maintain the full effects.  I am aware that the duration of treatment is dependent on many factors including but not limited to: age, sex, tissue conditions, my general health and lifestyle conditions, and sun exposure.  The correction, depending on these factors many last 3 months and in some cases shorter and some cases longer. I have been instructed in and understand post-treatment instructions and have been given a copy of them. I hereby voluntarily consent to treatment.  The procedure(s) has been explained to me. I have read the above and understand it.   My questions have been answered satisfactorily. I accept the risks and complication of the procedure.  I certify that if I have any changes occur in my medical history, I will notify aUK. I have read this informed consent and certify that I understand its contents in full. I have had enough time to consider the information from my practitioner and feel that I am sufficiently advised to consent to this procedure. I hereby give my consent to this procedure and have been asked to sign this form after my discussion with the aUK practitioner. I will follow all aftercare instructions as it is crucial I do so for healing. . I hereby release the aUK practitioner, the person(s) injecting the Botulinum A Toxin and the aUK facility from liability associated with this procedure
Botulinum A Toxin injection has been FDA approved for use in the cosmetic treatment for glabellar frown lines only - the wrinkles between the eyebrows. Injection of Botulinum A Toxins into the small muscles between the brows causes those specific muscles to halt their function (be paralyzed), thereby improving the appearance of the wrinkles. This paralysis is temporary and re-injection is necessary within three to four months. I understand that I will be injected with Botulinum A Toxin in the area of one, or more from the list below to paralyze these muscles temporarily Glabella, Corrugator Supercilii and Procerus muscles - Frown lines Frontalis Muscle - Forehead Lateral Orbital Lines: Orbicularis Oculi and Procerus Muscles - Crow’s Feet side of your eyes Bunny Lines (Transverse nasal) - around your nose Perioral Lines (Smoker’s Lines): Orbicularis Oris Muscle Marionette Lines: Depressor Anguli Oris and/or Trangularis Muscles Mentalis Dysfunction (Chin “Dents”): Mentalis Muscle Vertical Platysma Bands: Platysma Muscle Brow Lift Hyperhidrosis (excessive sweating): blocking the release of acetylcholine. (Acetylcholine is the body’s chemical which stimulates the sweat glands) Armpits: Axillary Palms: Palmaris Soles of the Feet: Plantaris I understand the goal is to decrease the wrinkles in the treated areas, or reduce sweating in the relevant areas listed above. Please sign to acknowledge you understand and consent to continuing with the procedure.
The possible side effects of Botulinum A Toxin include but are not limited to: RISKS: I understand there is a risk of swelling, rash, headache, and local numbness, pain at the injection site, bruising, respiratory problems, and allergic reaction. INFECTION: Infections can occur which in most cases are easily treatable bit in rare cases a permanent scarring in the area can occur. Most people have slightly swollen pinkish bumps where the injections went in, for a couple of hours or even several days. Although many people with chronic headaches or migraines often get relief from Botulinum A Toxin, a small percent of patients get headaches following treatment with Botulinum A Toxin, for the first day. In a very small percentage of patients these headaches can persist for several days or weeks. Local numbness, rash, pain at the injection site, flu like symptoms with mild fever, back pain. Respiratory problems such as bronchitis or sinusitis, nausea, dizziness, and tightness or irritation of the skin. Bruising is possible anytime you inject a needle into the skin. This bruising can last for several hours, days, weeks, months and in rare cases the effect of bruising could be permanent. While local weakness of the injected muscles is representative of the expected pharmacological action Botulinum A Toxin, weakness of adjacent muscles may occur as a result of the spread of the toxin. Treatments: I understand more than one injection may be needed to achieve a satisfactory result. Another risk when injecting Botulinum A Toxin around the eyes included corneal exposure because people may not be able to blink the eyelids as often as they should to protect the eye. This inability to protect the eye has been associated with damage to the eye as impaired vision, or double vision, which is usually temporary. This reduced blinking has been associated with corneal ulcerations. There are medications that can help lift the eyelid, however, if the drooping is too great the eye drops are not that effective. These side effects can last for several weeks or longer. This occurs in 2-5 percent of clients.
As Botulinum A Toxin injections are not an exact science, there might be an uneven appearance of the face with some muscles more affected by the Botulinum A Toxin than others. In most cases this uneven appearance can be corrected by injecting Botulinum A Toxin in the same or nearby muscles. However in some cases this uneven appearance can persist for several weeks or months. This list is not meant to be inclusive of all possible risks associated with Botulinum A Toxin as there are both known and unknown side effects associated with any medication or procedure. Botulinum A Toxin should not be administered to a pregnant or nursing appearance can persist for several weeks or months. Botulinum A Toxin should not be administered to a pregnant or nursing woman (breastfeeding). Additionally, the number of units injected is an estimate of the amount of Botulinum A Toxin required to paralyze the muscles. I understand there is no guarantee of results of any treatment. I understand the regular charge applies to all subsequent treatments. I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I further agree in the event of non-payment, to bear the cost of collection, and/or Court cost and reasonable legal fees, should this be required. I acknowledge I fully understand all that has been explained to me.

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