I confirm I have been informed that: BOTOX® is indicated for the temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at maximum frown (glabellar lines); moderate to severe lateral canthal lines (crow's feet lines) seen at maximum smile; moderate to severe crow's feet lines seen at maximum smile and glabellar lines seen at maximum frown when treated simultaneously in adults, when the severity of these lines has an important psychological impact for the patient. Like all medicines, BOTOX® can have side effects, 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. These adverse reactions may be related to treatment, injection technique or both. Diffusion of botulinum toxin into nearby muscles is possible when high doses are injected, particularly in the neck area. As expected for any injection procedure, pain/burning/stinging, swelling and/or bruising may be associated with the injection. Speak to your doctor if you are worried about this. Adverse reactions possibly related to the spread of toxin distant from the site of administration have been reported very rarely with botulinum toxin (e.g. muscle weakness, constipation, difficulty in swallowing, food or liquid accidentally going into the lungs which in some cases may lead to pneumonia). Injection of BOTOX® is not recommended in patients with a history of dysphagia (difficulty to swallow) and impaired swallowing. The chance of having a side effect is described by the following categories: Common - More than 1 out of 100 persons and less than 1 out of 10 persons - Uncommon side effects are: Injection site pain and/or tingling or numbness Injections in the fan-shaped lines from the corner of the eyes, when treated at the same time as injections in the forehead for vertical lines Common side effects are: Injection site bruising. Uncommon side effects are: Injection site bleeding and/or pain. The following additional side effects have been reported for BOTOX® sincet face and airways, difficulty in breathing), loss of nerve supply to/shrinkage of injected muscle, respiratory depression and/or respiratory failure, aspiration pneumonia (lung inflammation caused by accidentally breathing in food, drink saliva or vomit), chronic disease affecting the muscles (myasthenia gravis). Blurred vision, difficulties in seeing clearly, Slurred speech, strabismus numbness, tingling and pain in hands and feet, fainting, pain/numbness or weakness starting from the spine, drooping of the muscles on one side of the face, weakness of the face muscles, difficulty moving the arm and shoulder, decreased skin sensation, muscle pain, abdominal pain, diarrhoea vomiting, loss of appetite, dry mouth, feeling sick, fever, different types of red blotchy skin rashes, feeling generally unwell, speech problems, itching excessive sweating, hair loss, loss of eyebrows, decreased hearing, noise in the ear, feeling of dizziness or "spinning" (vertigo). Allergic reactions, difficulties to swallow, speak or breathe, have been reported rarely when botulinum toxin type A has been used for other uses. Visit your doctor immediately if such signs develop after BOTOX® treatment. If any of the side effects get serious, or if you notice any side effects not listed in this leaflet, please tell your doctor or pharmacist. BOTOX® should only be administered by medically qualified physicians with appropriate qualifications and expertise in this treatment and having the required equipment. 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. The aesthetic effects of BOTOX® last for an average of 3-4 months but will vary depending on the condition of the skin, area treated, amount of product injected, injection technique and lifestyle factors such as sun exposure and smoking. After treatment, please avoid extreme facial expressions, alcohol consumption and applying make up for 12 hours. Please avoid extreme sun exposure, UV light, freezing temperatures and saunas for 2 weeks after treatment. Uncommon - More than 1 out of 1,000 persons and less than 1 out of 100 persons Injections in the forehead for vertical lines. Common side effects are: Headaches, drooping eye lid, skin redness, localised muscle weakness, face pain. Uncommon side effects are: Infection, anxiety, numbness, dizziness, inflammation of the eyelid, eye pain, visual disturbance, nausea (feeling sick), dry mouth, skin tightness, swelling (face, eyelid, around the eyes), sensitivity to light, itching, dry skin, muscle twitching, flu syndrome, lack of strength, fever, Injections in the fan-shaped lines from the corner of the eyes. Common side effects are: Swelling of the eyelid, injection site bleeding and/or bruising. Please ask your treating practitioner for a copy of the BOTOX® package insert. I confirm that my treating practitioner has: Provided me with sufficient information about the treatment detailed in order to make an informed decision Given me the opportunity to ask all remaining questions I may have about the treatment, and has answered them to the best of their ability Given me the time to consider the treatment detailed overleaf Received the relevant medical history information from me to the best of my knowledge I therefore consent to receiving the described treatment by my treating practitioner.Botox Aftercare: Please indicate that you understand: • You can help activate the Botox by gently exercising the muscles that have been treated i.e frown & smile as frequently as possible. • Some patients experience slight discomfort around the treatment area for a short time after treatment. • Bruising can be avoided or minimised by avoiding aspirin and alcohol for 24 hours pre and post treatment. • You may experience temporary swelling or bruising around the site of treatment. This will usually settle within a day or two. Some patients can experience a headache following treatment for which you may take paracetamol. • The results are not permanent and the duration will differ from patient to patient. • The treatment normally takes 4-10 days to take effect. Side effects, if they occur, are usually temporary and mild to moderate. The most common reported side effects: Tenderness Bruising Temporary headache Drooping of the eye lid or brow Excessive watering of the eye Mild inflammation of the surface of the eye Less common side effects include: Inflammation of the surface of the eye Eversion or inversion of the eyelids Light sensitivity/double vision Dizziness, rash, tiredness Facial weakness/droop/asymmetry Allergic reaction Should you experience any of these symptoms following treatment, please contact your practitioner. When you feel the muscles relaxing (4-10 days) gently massage the area with your regular moisturiser twice a day. We do hope that you are happy with your treatment. Please remember, however, that the treatment will usually only last for three to four months and movement will start to return any time from 4 weeks.