Beautay

Anti-wrinkle injections consent form

Add your clinic details and print a complete botulinum toxin consent form. It covers the treatment description, known risks, contraindications, aftercare and the declarations your client signs.

Your clinic details

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Your professional registration number if you have one.

The number a client should use if something goes wrong outside opening hours.

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Your clinic name

Consent to treatment

Consent to Treatment: Botulinum Toxin (Anti-Wrinkle Injections)

Client details

Full name
Date of birth
Address
Contact number
Email address

Treatment description

Botulinum toxin type A is a prescription only medicine. It is injected into specific facial muscles to soften the lines caused by repeated movement. The effect develops over three to fourteen days and typically lasts three to four months.

The product is used off licence for some cosmetic indications. Your practitioner will explain which areas are being treated and how many units are being used.

Areas being treated

  • Forehead lines
  • Frown lines (glabella)
  • Crow's feet (lateral canthal lines)
  • Other (as recorded in your treatment notes)

Common and expected effects

  • Redness, swelling or small raised bumps at the injection sites, usually settling within a few hours
  • Bruising, which can last up to two weeks
  • Mild headache in the first 24 to 48 hours
  • Tenderness at the injection sites

Less common risks

  • Drooping of the eyelid or eyebrow, which is temporary but can last several weeks
  • Asymmetry between the two sides of the face
  • An uneven or unexpected result requiring a review appointment
  • Dry eye or altered tear production
  • Difficulty with certain facial expressions while the product is active
  • Allergic reaction, which is rare
  • Spread of the product to nearby muscles causing temporary weakness

Reasons treatment may not be suitable

Tell your practitioner before treatment if any of the following apply to you.

  • You are pregnant, breastfeeding or trying to conceive
  • You have a neuromuscular condition such as myasthenia gravis or Lambert Eaton syndrome
  • You have a known allergy to botulinum toxin or to albumin
  • You have an active skin infection or inflammation in the treatment area
  • You are taking aminoglycoside antibiotics or other medicines affecting neuromuscular transmission
  • You have had a previous adverse reaction to botulinum toxin
  • You have a bleeding disorder or take anticoagulant medication

Aftercare

  • Stay upright for four hours after treatment
  • Avoid rubbing, massaging or applying pressure to the treated areas for 24 hours
  • Avoid strenuous exercise, saunas, steam rooms and sunbeds for 24 hours
  • Avoid alcohol for 24 hours
  • Do not have facials, chemical peels or other facial treatments for two weeks
  • Contact the clinic if you develop drooping, difficulty swallowing or breathing, or any effect that concerns you

Results and review

Results are not permanent and repeat treatment is needed to maintain the effect. A review appointment is usually offered two weeks after treatment. Any adjustment is at the clinical discretion of your practitioner.

No practitioner can guarantee a specific outcome. Individual results vary with anatomy, muscle strength and how your body responds to the product.

Declaration

Please initial each statement.

  • I have read and understood the information above, including the risks and the aftercare instructions.
  • I have had the opportunity to ask questions and I am satisfied with the answers given.
  • I have given a full and accurate medical history, including all medicines, supplements and allergies.
  • I understand that no guarantee has been given about the result and that further treatment may be needed at additional cost.
  • I understand that botulinum toxin is a prescription only medicine and may be used off licence for this indication.
  • I consent to clinical photographs being taken and stored as part of my treatment record.
  • I consent to the treatment described above.

Client

Signature
Print name
Date

Practitioner

Signature
Print name
Date

Good practice

Getting consent right

  • Consent should be taken by the practitioner performing the treatment, not by reception staff.
  • Allow a cooling off period between consultation and treatment for clients who are new to injectables.
  • Keep the signed form with the client record for the full retention period required by your indemnity provider.
  • Re-consent at every appointment rather than relying on a form signed months earlier.

Important

This template is a starting point, not legal or clinical advice. Review the wording with your insurer or indemnity provider and adapt it to your own practice, products and protocols before you use it with clients.

Other templates

Stop printing consent forms

Beautay sends the right form when the appointment is booked, stores the signed copy against the client record, and prompts you to re-consent at the next visit.

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