Please read the full consent carefully, then sign below.
I, [your name],
ID No. [ID no.],
do hereby give my fully informed and voluntary consent to receive anti-wrinkle
(Botulinum Toxin) injections administered by
Dr. Katrina Bonnici,
a registered Doctor trained in administering these treatments.
I understand that Botulinum Toxin is a prescription medicine and agree to undergo
treatment with the following conditions:
Medical History: I have provided a comprehensive and truthful account
of my current and past medical history, including any medications and supplements I am
currently taking, and have disclosed any allergies or adverse reactions. I accept that it
is my responsibility to inform Dr. Katrina Bonnici of any changes to
my medical condition before each treatment.
Side Effects: I am aware that the treatment may result in temporary
side effects such as swelling, bruising, redness, or pain. I have been advised to avoid
aspirin, anti-inflammatory medications, and alcohol before the treatment and for 24 hours
after the treatment to minimise the risk of bleeding and bruising.
Risks & Complications: I acknowledge the possibility of more
serious complications including but not limited to: hypersensitivity, allergic response,
anaphylactic reaction, asymmetry of facial expressions, muscle weakness, twitching,
bruising/swelling/skin redness, stinging/burning, headaches, 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 the treatment site, and remaining muscle movement.
Treatment Procedure: The procedure will start with a consultation to
assess suitability for the treatment. The treatment area will be cleaned with a
disinfectant solution before the procedure, and a strict aseptic technique will be used
to minimise the risk of infection.
Immediate Treatment: In the event of any adverse reaction, immediate
treatment may be required using medicines prescribed or administered by a Doctor.
Post-Treatment Advice: I have received both verbal and written
post-treatment advice, and understand the importance of following these instructions.
Product Information: Allergan Botox, Merz Pharma Bocouture, Letybo,
Alluzience, Xeomin.
I recognise that the results of Botulinum Toxin injections are not permanent and
that repeat treatments may be required to maintain the desired outcome. I reserve the
right to withdraw my consent and discontinue the treatment at any time for any reason.
