Name * First Name Last Name Email * Post code * Prescribing Doctor * Clinician details * Information * 1. Anti-wrinkle injections use a purified natural protein to relax muscles. There are several different brands, which are almost identical ("Botox", "Xeomin", "Dysport"). The treatment is approved and safe when prescribed by a doctor. 2. It usually takes about 2 weeks for the full effect of the medication to be visible. The effects of the medication are not permanent. They usually last 3-4 months. Deep wrinkles will become gradually less with repeat dosing. For the best results we recommend repeat treatments every 3 or 4 months. 3. The aim of our therapy is to use subtle amounts of anti-wrinkle medication to create a natural, fresher, more youthfull look, without limiting your ability to express yourself. We will not eliminate all signs of aging, but instead aim to produce a soft, rested face. Ideally, no one will know we were there! 4. We will consult with you about where you feel treatment would benefit you most, and we will also offer our recommendation. Each treatment will be tailored to you individual needs. Prices are per unit of anti-wrinkle injection, and the amount of units may vary. We will confirm the plan with you before we proceed. 5. The procedure will involve several injections with a very fine needle in the areas discussed in your treatment plan. You may feel some slight discomfort but it is not painful. It will take about 15 minutes of sitting comfortably. 6. You should avoid alcohol 3 hours before and 3 hours after the procedure, as alcohol causes blood vessels on the skin to enlarge, which may distribute the medication over a wider area than planned. For the same reason, you should avoid exercise for the hour before and three hours after the procedure. I confirm Consent for Procedure At the doses used for cosmetic therapy, anti-wrinkle injections are very safe, and are typically very well tolerated. People who should not have anti-wrinkle injections include: 1. People who have previously had a reaction to Anti-wrinkle injections * I confirm 2. People who are pregnant or breastfeeding. * I confirm 3. People who suffer from neuromuscular disorders such as myasthenia gravis or Eaton Lambert syndrome. * I confirm 4. People who have an infection or active acne at the proposed site of injection. * I confirm The risks involved in Anti- Wrinkle injections: 1. The treatment may not work as well as you would like. For example, wrinkles may not smooth out as much as you were hoping for. We will follow-up with you two weeks after your treatment to see how you are feeling about the effects. Initial * I confirm 2. The treatment cause temporary drooping or raising of the eyebrows or corners of the mouth. We aim to avoid this through correct technique and minimal dosing. Initial * I confirm 3. Bleeding, bruising or infection, while unexpected, may develop at the injection site. Rarely, an infection may become complicated. If you suspect an infection has occurred please let your doctor know by contacting your clinic. Initial * I confirm By signing here I indicate that none of the at-risk categories detailed above apply to me, and that I have read, understand and accept the risks of the procedure outlined above. Any questions I have about the treatment have been encouraged and answered. I consent for the procedure to go ahead as discussed with my clinician * PRINT NAME Consent for Photographs I consent for my photographs to be taken for the purpose of clinical review * Before and after photos are a clinical requirement to monitor the effect of treatment as a form of medical records. I consent I do not consent I consent for my photographs/videos to be used on the social media accounts of Aesthetics by Renee * If you would prefer your eyes to be hidden, please let your clinician know. I consent I do not consent Thank you! Anti- Wrinkle Consent