CONSENT FOR BOTULINUM TOXIN TREATMENT
I consent to have Botulinum Toxin injected into my facial muscles.
I understand that the toxin is derived from bacteria and is used to temporarily paralyse muscles of facial expression.
I have had the procedure explained to me and have had the opportunity to ask questions.
I also understand that the following complications may occur and accept these risks of treatment.
MOST COMMON
1. Bruising which may persist for days to a week.
2. Swelling and/or redness at the site of injection for up to a couple of days.
3. Headache lasting hours to a few days.
4. Undesirable change in position of eyebrows.
5. Incomplete result or recruitment of adjacent muscles.
LESS COMMON
1. Ptosis (droop) of eyelid or brow. This may last days to months.
2. Flu like symptoms, lasting up to one week.
3. Changes in smile, incompetent mouth, difficulty speaking and asymmetry.
RARE
1. Allergy to Botulinum toxin, saline or preserved saline
2. Infection at needle sites.
3. A very small percentage of the population does not respond to the treatment. We are unable to
identify these patients prior to treatment.
4. There is less than 1% chance that headaches will last for some weeks. If this happens, they can be quite debilitating.
5. The Botulinum Toxin contains human albumin, a derivative of human blood. Effective donor screening and the product manufacturing process means the risk of transmission of any viral disease is extremely remote.
6. Double vision, vertigo and nausea which can be debilitating.
I understand that complications may occur with any procedure and I accept the possible risks associated with this, including any additional financial expenses that may be associated with hospital care,
anaesthetic or professional fees.
BY signing below, I acknowledge that I have completed the check list and answered all questions honestly.
Caution : I understand that I SHOULD NOT HAVE this treatment if I am pregnant, trying to become pregnant, or breastfeeding.
I am aware, and I consent to my treatment being carried out by :
Bonnie Beauty
info@bonniebeauty.co.nz
64+2102354207
375A Blockhouse Bay Road
Blockhouse Bay, Auckland 0600