Please fill in the form below in order to prepare us for your appointment for Botulinum Toxin. We will review this in advance of your appointment – if there are any problems, we will contact you – otherwise we look forward to seeing you at your arranged appointment time. It can be helpful to be a few minutes early for the appointment to allow us some extra time to discuss all the available options with you.

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Botulinum Toxin is not suitable for everyone, before proceeding you must tick and agree to ALL OF the following statements: *

• I have not had wrinkle relaxing injections in the last 8 weeks
• I have never had an allergic reaction to botulinum toxin
• I am not currently pregnant or breastfeeding
• I have not been diagnosed with body dysmorphia
• I do not currently have a neuromuscular disorder that affects the muscles in my face
• I have never had bells palsy, facial paralysis or any similar condition that would affect this treatment

Although Botulinum itself is very safe, and has very few side effects, there are some medical conditions where we need to discuss your options in person before proceeding. Please tick any below that apply to you.

• I am on blood thinners – such as aspirin, clopidogrel or apixiban.
• I take more than 2000mg of Omega-3 oil every day
• I am generally prone to bruising
• I have had chickenpox or shingles in the last 3 months
• I have been diagnosed with neuropathy

Please give us a brief medical history, including any medicines you are taking and any chronic long term conditions you are being treated for. *

If you have not had botulinum toxin before, we recommend reading this NHS guide https://www.nhs.uk/conditions/cosmetic-procedures/non-surgical-cosmetic-procedures/botox-injections/ *

• I understand the possible risks and side effects of botulium therapy

Please tick the box below to agree to the following statement: "Results may vary, and there are risks of complications which are most commonly bruising, pain/swelling at the injection site, and possible infection. I understand these risks (however minor) and accept them as part of the therapy." *

• Consent

By ticking this box you consent to treatment with botulinum toxin, if it is indicated after a consultation with my aesthetician. I consent to you processing my data in order to provide this consultation and treatment. *

• Consent

It would help us prepare if you could take a clear photograph of your face – from the front, while frowning and doing your best to show us the wrinkles and fine lines you want to be treated. This is not compulsory, but will help us prepare for your visit with the correct product and doses. You can upload multiple images from different angles if you have different areas to be treated.

Click or drag files to this area to upload. You can upload up to 6 files.

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