CLIENT CONSENT INFORMATION

Name *

First Name

Last Name

DOB *

MM

DD

YYYY

Gender *

Male

Female

Transgender

Non-binary/non-conforming

Prefer not to respond

Is this your first injectable treatment i.e. Botox/dermal fillers/vitamin injection? *

Yes

No

Is this your first treatment performed by Burrows Lane Aesthetics Clinic? *

Yes

No

Please select the treatments that you are interested in having: *

Dermal fillers

Botulinum A. Toxin (Botox)

Dissolver

Vitamin injection

Are you pregnant, or is there any possibility that you may be pregnant?

Yes

No

N/A

Are you breastfeeding?

Yes

No

N/A

Have you ever been diagnosed with or suffered from any of the following:

Please tick any that apply

Pigment disorders?

Increased scar formation and/or keloid scarring?

Increased light sensitivity?

Herpes infections?

Acne?

Psoriasis or any other active skin condition in the areas(s) you wish to have treated?

Amyotrophic Lateral Sclerosis (ALS)?

Myasthenia Gravis?

Lambert-Eaton Syndrome or Multiple Sclerosis?

Impaired ability to swallow or Dysphagia?

Angina or Cardiac Infarction?

High/Low blood pressure?

Emotional/neurological disorders e.g seizures (epilepsy), depression, anxiety?

M.E (Myalgic Encephalomyelitis)?

Migraines?

Bell’s Palsy or a stroke?

Glaucoma?

Asthma?

Diabetes?

Thyroid problems?

HIV?

Hepatitis A/B/C?

Rheumatoid Arthritis or other Autoimmune diseases?

Nosebleeds?

Bruises (after light touch)?

Coagulation disorders or bleeding disorder?

Allergies e.g. hay fever, foods, drinks, latex, plasters?

Hypersensitivities e.g. to collagen, lidocaine, painkillers, anaesthesia, medications?

Blindness, visual impairments or double vision?

Have you ever been admitted to hospital with a severe allergy? *

Yes

No

Do you or does anyone in your family suffer from a hereditary disease? *

Yes

No

Have you ever been diagnosed with a severe medical condition, requiring medical treatment and/or hospital admission? *

Yes

No

Are you currently undergoing any desensitisation treatment? *

Yes

No

Have you recently taken any medication or are you currently taking medication e.g. painkillers, coagulation inhibitors, antibiotics, steriods, muscle relaxents (Asprin, Warfarin, Ibuprofen), St Johns Wort or herbal preperations, vitamins and/or supplements? *

Yes

No

Have you taken Acne medication in the past 12 months e.g. Roaccutane, Isotretinoin? *

Yes

No

Have you had surgery in the last 6 weeks? *

Yes

No

Are you planning to undergo dental treatment in the near future? *

Yes

No

Have you previously had any of the following treatment to the facial area: Laser skin peels, facelift, IPL skin resurfacing, plastic surgery? *

Yes

No

Have you ever suffered an injury to the facial area? *

Yes

No

Do you have a phobia of blood and/or needles? *

Yes

No

Are you prone to bruising? *

Yes

No

Do you have a tendancy to faint? *

Yes

No

Do you have a tendancy to develop cold sores, or have had one in the past 2 weeks? *

Yes

No

Have you ever had an abnormal reaction to local anaesthetics (injection/cream)? *

Yes

No

Have you recieved Botox injections previously? *

Yes

No

Have you recieved Dermal Filler injections previously? *

Yes

No

Have you recieved any Botox or Dermal Filler injections in the last 4 weeks? *

Yes

No

Have you experienced any abnormal reactions or allergies to Botox or Dermal Filler injections previously? *

Yes

No

Do you have any permanent implants in you face? *

Yes

No

Name/Signature *

{By completing this field you are adding your signature to this form}.

First Name

Last Name

Todays Date *

MM

DD

YYYY

This form is not just a formality – it’s a record of your decision to consent to a procedure having considered the risk of both positive and negative outcomes and medical risks listed below, and the impact they may have on your well-being. Please sign the box below to confirm you have read, understood and discussed each section as required with your clinician. What is being injected? Botulinum Toxin, branded Azzalure, Botox or Bocoture, is a purified protein produced by the bacterium clostridium botulinum. The product causes muscle relaxation and suppresses sweating for 2-6 months on average (with a wide variation between individuals) by temporarily disrupting nerve activity to muscles and sweat glands. By signing this form, you agree and understand that some treatments are given off label as deemed appropriate by the prescribing clinician and/or injector. What are the side effects and risks? There are several possible temporary side effects that may occur, although not everybody gets them. In general, side effects occur within the first few days following injection. They usually last only for a short time, but they may last for several months and in rare cases, longer. The following reactions are generally described as mild to moderate and typically resolve spontaneously a few days after treatment. These reactions are normal and are to be expected: - Transient headache, swelling, redness, inflammation, bruising, bleeding, pain, tenderness, twitching, itching, numbness, or other changes in sensation Other more uncommon side effects include: - Puffiness/oedema around the eyes, eye pain, dry eyes, allergy including anaphylaxis (very rare but possible), asymmetry (unevenness), temporary drooping of facial features including eyelids, eyebrows, under eyes, cheeks and mouth, double or blurred vision, fainting, tinnitus, nausea, dizziness, dry mouth, flu symptoms, influenza, bronchitis, inflammation of the nose and throat and infection - The theoretical risk of complications unique to certain individuals is so far unknown If you experience uncommon or rare side effects after receiving treatment, or experience any side effects not listed above, for example, allergic reactions, excessive muscle weakness or difficulty swallowing, speaking or breathing, please seek emergency medical care immediately. LIMITATIONS AND ALTERNATIVES Botulinum Toxin is best at treating dynamic facial lines (those caused by facial muscle activity). Lines present at rest may or may not improve and can be unpredictable. Additionally, very deep creases may not be completely resolved with this treatment and repeat, or alternative treatments may be required. This treatment is temporary, meaning it has to be repeated on a regular basis to remain effective. Too frequent or excessive dosing of Botox 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. If you are pregnant or breast feeding, this treatment is not recommended. FOLLOW-UP APPOINTMENT Free adjustment injections are available during one follow-up appointment which can occur up to 4 weeks after the first treatment. Appointments and additional injections thereafter will incur a charge. DISSATISFACTION With all treatments the degree of improvement cannot be predicted or guaranteed. The outcome’s subjective nature means dissatisfaction is a possible outcome regardless of effectiveness of treatment. The effects of all treatments will gradually wear off and additional treatments may be necessary to maintain the desired effect. Some patients may be more or less sensitive to the effects of the treatment and occasionally the treatment wears off very quickly or does not work at all. By signing/completing the name field below I confirm that: – I have read this form carefully and considered the side effects, risks, complications and uncertainty of the outcomes and decided the treatment is still in my best interests - I confirm I have considered alternatives to this treatment, including no treatment (doing nothing), topical creams, chemical peels, laser treatments, surgical denervation, forehead/brow lift, facelift, or hyaluronic acid treatments and elected at this time that Botulinum Toxin is the best option for me. - I have disclosed my full medical and drug history to my injector, and I am aware that many medications increase the risk of bruising and will prolong my recovery time, including but not limited to Vitamin E, Asprin, Motrin, Clopodogrel, Warfarin and others. - I have been given the opportunity to ask questions, and these have been answered to my satisfaction - I have been given the opportunity to discuss all of the details of the treatment, my past treatments and my past medical history with the injector, and shared all the information the injector needs to plan the treatment - I understand some patients may be more or less sensitive to the effects of the treatment and occasionally the treatment wears off very quickly or does not work at all. This is a chance I am willing to take and I agree to be personally and fully responsible for all fees and payments related to my treatment, and I understand that no refunds are issued due to all of the above – My treating practitioner has given me the time to consider the treatment – I have not knowingly withheld any relevant medical history or surgical information - After treatment, I agree to follow the Aftercare Regime instructions given to me by the clinic - I understand photographs are taken and stored for 7 years as part of my clinical record - I consent to anonymised photographs of my treatment to be used by the clinic for promotional and educational purposes. I understand that I will not be entitled to any payment as a result of these images/videos. {By completing this field you are adding your signature to this form}.

First Name

Last Name

Todays Date *

MM

DD

YYYY

This form is not just a formality – it’s a record of your decision to consent to a procedure having considered the risk of both positive and negative outcomes and medical risks listed below, and the impact they may have on your well-being. Please sign the box below to confirm you have read, understood and discussed each section as required with your clinician. What is being injected? Hyaluronic Acid injectables include branded products such as Juvederm, Restylane, Boltero, Teosyal, Profhilo and many others. They are used to improve the appearance of lines, correct and increase volume loss or alter proportions. They are made of mainly water, hyaluronic acid, lidocaine anaesthetic and stabilising molecules such as BDDE (1,4 – Butanediol Diglycidyl Ether) What are the side effects and risks? There are several possible temporary side effects which may occur, although not everybody gets them. In general, side effects occur within the first few days following injection. They usually last only for a short time, but they may last for several months and in rare cases may be permanent. Common reactions include redness, swelling, pain, itching, bruising, bleeding, headache, numbness, and tenderness at the treatment site. These reactions are generally described as mild to moderate and typically resolve spontaneously within 2 weeks after treatment. These reactions are normal and are to be expected. INJECTION RISKS Trauma during the procedure is caused by needles and cannulas passing through tissue, and includes bleeding, bruising, haematoma (a larger collection of blood in the skin, outside of blood vessels), damage to underlying structures including veins, arteries, nerves, salivary glands, lymph nodes, bone, muscle and other soft tissue structures are possible. In rare cases this could cause continuous problems in appearance, sensation or function and may require medical intervention to treat or may be permanent. Most traumatic injuries heal completely on their own. INFECTION RISKS Bacterial, viral or fungal infections can occur post procedure. Infections can cause redness and swelling and resolve or progress into abscesses or biofilms which can be slower to recover. Rarely infections occur months later as ‘biofilm reactions’. Symptoms include itching and a lumpy or ‘thick’ feeling at or just under the skin. Injections into the lip area could trigger a recurrence of cold sores (Herpes simplex infections) which may require treatment. These problems may resolve in time, but medical intervention may be required in some cases, and long-term effects may persist in rare cases. REACTIONS Reactions rarely occur but can include an immediate reaction causing swelling, and very rarely life-threatening anaphylaxis. Delayed reactions localised to the skin can cause nodules, lumps or bumps, or very rarely sterile abscesses. These may occur soon after the procedure or months later. They may require treatment and may leave permanent effects on the appearance, sensation and function of the areas affected. The chance of a reaction is reported to be 0.5% or 1 in 200. The chance of delayed reaction increases if you have an active autoimmune disease or an active immune system including viral or bacterial infections elsewhere. LUMPS, BUMPS AND SWELLINGS Unwanted visual side effects may cause dissatisfaction or distress, and include an increase in asymmetry, swelling, lumps, bumps, puffiness or surface irregularities. These non-inflamed filler side effects are temporary and treatable with full resolution likely. SKIN CHANGES Procedures are rarely associated with pigment changes, the formation of thread veins or new capillaries, and other blemishes. If they occur, they may either recover, require further treatment or be permanent. BLOOD VESSEL BLOCKAGE In rare instances the blood supply can be block by filler. This can cause local tissue injury called ‘necrosis’, which can result in permanent scarring. There are extremely rare cases in which blood supply to the eye or parts of the brain being affected causes blindness and stroke. Seeking help immediately if you suspect blood vessel occlusion is vital to prevent scarring. If you experience uncommon or rare side effects after receiving treatment, please seek emergency medical care immediately. LIMITATIONS AND ALTERNATIVES If you are pregnant or breast feeding, this treatment is not recommended. This treatment is temporary, meaning it has to be repeated on a regular basis to remain effective. Too frequent or excessive dosing of Dermal Fillers may increase the risk of migration, lumps, bumps and unevenness, which may require a dissolving treatment to resolve. ADDITIONAL APPOINTMENTS Further treatments may be necessary to achieve and maintain the desired effect and further charges will apply if an additional appointment is required and more product is used. Adjustments requiring more product will incur a charge. DISSATISFACTION With all treatments the degree of improvement cannot be predicted or guaranteed. The outcome’s subjective nature means dissatisfaction is a possible outcome regardless of effectiveness of treatment. Some patients may be more or less sensitive to the effects of the treatment and occasionally the treatment wears off very quickly or does not work at all. By signing/completing the name field below I confirm that: – I have read this form carefully and considered the side effects, risks, complications and uncertainty of the outcomes and decided the treatment is still in my best interests - I have disclosed my full medical and drug history to my injector, and I am aware that many medications increase the risk of bruising and will prolong my recovery time, including but not limited to Vitamin E, Asprin, Motrin, Clopodogrel, Warfarin and others. - I have been given the opportunity to ask questions, and these have been answered to my satisfaction - I have been given the opportunity to discuss all of the details of the treatment, my past treatments and my past medical history with the injector, and shared all the information the injector needs to plan the treatment - I understand some patients may be more or less sensitive to the effects of the treatment and occasionally the treatment wears off very quickly or does not work at all. This is a chance I am willing to take and I agree to be personally and fully responsible for all fees and payments related to my treatment, and I understand that no refunds are issued due to all of the above – My treating practitioner has given me the time to consider the treatment – I have not knowingly withheld any relevant medical history or surgical information - After treatment, I agree to follow the Aftercare Regime instructions given to me by the clinic - I understand photographs are taken and stored for 7 years as part of my clinical record - I consent to anonymised photographs of my treatment to be used by the clinic for promotional and educational purposes. I understand that I will not be entitled to any payment as a result of these images/videos. {By completing this field you are adding your signature to this form}.

First Name

Last Name

Todays Date *

MM

DD

YYYY