Botulinum Toxin (Anti-Wrinkle) Consent — Consent Form | Elite Clinique

Botulinum Toxin (Anti-Wrinkle) Consent

Elite Clinique | Consent Form

This consent form is specific to the administration of botulinum toxin type A injections for the treatment of dynamic wrinkles and fine lines. This form must be completed in addition to the General Treatment Consent form.

Botulinum toxin is a prescription-only medicine (POM) that is prescribed by a qualified prescriber (doctor, dentist, pharmacist prescriber, or nurse prescriber) and administered or supervised in accordance with the Human Medicines Regulations 2012. It works by temporarily blocking the release of acetylcholine at the neuromuscular junction, reducing the contraction of targeted muscles and thereby softening the overlying wrinkles.

COOLING-OFF PERIOD: In accordance with JCCP and CPSA guidance, a minimum 48-hour cooling-off period must elapse between your initial consultation and this treatment. If you are attending for a repeat treatment of the same areas and have had a recent consultation, this requirement may be waived at your practitioner's discretion.

ALTERNATIVES: Alternative treatments for wrinkles may include topical retinoids, chemical peels, microneedling, dermal fillers, laser treatments, or no treatment. Your practitioner will have discussed any alternatives relevant to your presentation.

Risks & Side Effects

Very Common

Affects more than 1 in 10 people

Redness, swelling, and minor bleeding at injection sites (resolves within hours)

Common

Affects up to 1 in 10 people

Mild headache following treatment (typically resolves within 24 hours)
Bruising at injection sites (may last 7-14 days)
Temporary localised numbness or altered sensation

Uncommon

Affects up to 1 in 100 people

Temporary eyelid or eyebrow drooping (ptosis) — typically resolves within 2-6 weeks
Asymmetric results requiring adjustment at review appointment
Flu-like symptoms for 24-48 hours following treatment

Rare

Affects fewer than 1 in 1,000 people

Development of antibodies to botulinum toxin, reducing future treatment efficacy
Allergic reaction to botulinum toxin or any excipient in the product
Spread of toxin to unintended muscles causing temporary muscle weakness beyond the treatment area

Contraindications

Treatment may not be suitable if you:

✕Pregnancy or breastfeeding
✕Neuromuscular disorders including myasthenia gravis, Lambert-Eaton syndrome, or motor neuron disease
✕Known allergy or hypersensitivity to botulinum toxin type A or any excipient (e.g. human serum albumin)
✕Active skin infection or inflammation at or near the intended injection sites
✕Current use of aminoglycoside antibiotics, spectinomycin, or other agents interfering with neuromuscular transmission
✕Bleeding disorders or current use of anticoagulant medication (increased bruising risk — discuss with your practitioner)
✕Previous adverse reaction to any botulinum toxin product

Patient Declaration

By signing this consent form, I confirm that:

1I confirm that at least 48 hours have elapsed since my initial consultation for this treatment, or I am attending for a repeat treatment of the same areas following a recent consultation.
2I understand that botulinum toxin is a prescription-only medicine and has been prescribed specifically for me by a qualified prescriber following a clinical assessment.
3I understand that results typically become apparent within 3-14 days and that the full effect may not be seen for up to 2 weeks. Results typically last 3-4 months, after which muscle activity gradually returns.
4I understand that repeat treatments are required to maintain results and that treatment intervals should not be less than 3 months apart.
5I understand that a review appointment may be offered at 2 weeks to assess the outcome and carry out any adjustments if clinically appropriate.
6I will avoid rubbing, massaging, or applying pressure to the treated areas for at least 4 hours following treatment.
7I will remain upright and avoid lying flat for at least 4 hours following treatment.
8I will avoid strenuous exercise, saunas, steam rooms, and excessive alcohol consumption for 24 hours following treatment.
9I will contact the clinic promptly if I experience any unexpected side effects, including difficulty swallowing, breathing difficulties, or spreading muscle weakness.

Note: This is an informational copy of our consent form. The formal consent process takes place in person with your practitioner before treatment.