Name(Required) First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Phone(Required)Email(Required) I am voluntarily consenting to the injection of Botulinum Toxin to change my appearance.(Required) I acknowledge that the practice of aesthetic treatment is not an exact science and therefore that no guarantee can be given as to the results of the treatment outcome. I accept and understand that the goal of this treatment is improvement, not perfection, and that there is no guarantee that the anticipated results will be achieved(Required) I understand the risks and conditions associated with dermal Botulinum Toxin treatment and that it is an elective cosmetic procedure.(Required) I acknowledge that whilst complications from this procedure are uncommon, they do sometimes occur. Side effects may (depending on the product used) include redness, swelling, bruising, discomfort, tenderness, swelling, and itchiness – these side effects may last from a few seconds up to a couple of weeks or more. I acknowledge that I have read and fully understand the list of potential side effects.(Required) I have provided the practitioner with all my medical history and/ or medication details. I fully accept any consequences of not providing full details and will not hold practitioner liable in respect of the same.(Required) I am happy to proceed on the basis that existing facial asymmetry may not be completely rectified.(Required) There is a small risk of infection of the treated skin area after the procedure, although this is not expected to occur due to the sterility of the medical devices used.(Required) I understand that I am undertaking this treatment knowing the full facts, side effects, treatment outcomes and complications and I will not hold the clinic responsible should any issues mentioned above occur.(Required) I give full consent to the use of my before and after images for marketing purposes, providing all identifying features are covered and that there is no way to identify myself from the image. Images will be kept for 6 years and may be used in the event of a claim being brought against us. They will be stored on a password encrypted hard drive.(Required) Under GDPR rule, I understand that I have full access to all data held on me. This data will be held by the clinic for no longer than 6 years for insurance purposes, after which, digital information will be deleted permanently, and paper documents will be destroyed. All information on myself is kept on password encrypted hard drives or locked in filing cabinets to which only selective staff members have access. None of my personal data will be sold or used for anything other than to provide the services of this clinic.(Required) Do you consent to the use of a local anaesthetic?(Required) Yes No Are you allergic to local anaesthetics, do you have a history of anaphylactic shock (severe allergic reactions)?(Required) Yes No Do you suffer from any known allergies? If yes, please specify(Required) Have you taken oral retinoids (Roaccutane) in the last 12 months?(Required) Yes No Are you using topical retinoids/Vitamin A products?(Required) Yes No Do you have active acne with papules or pustules?(Required) Yes No Are you taking Aspirin, Warfarin, other anti-coagulant treatments or any other medication or dietary supplements such as Omega-3 that can affect platelet function and bleeding time?(Required) Yes No Do you have or have you had any form of skin cancer?(Required) Yes No Are you taking/receiving steroids, chemotherapy or radiotherapy?(Required) Yes No Are you taking any other medication? If Yes, please specify(Required) Do you suffer from any illness e.g. diabetes, angina, epilepsy, hepatitis, auto immune disease?(Required) Yes No Do you suffer from keloid or hypertrophic scars?(Required) Yes No Do you have a history of herpes simples (cold sores) or other skin infections?(Required) Yes No Have you undergone a laser resurfacing or skin peel in the last 6 weeks?(Required) Yes No Are you pregnant or is there any possibility that you are pregnant?(Required) Yes No Are you breastfeeding?(Required) Yes No Will you refrain from intensive sunlight exposure and/or artificial UV exposure for a period of at least 2 weeks?(Required) Yes No Will you use topical sun protection products with an SPF 30+ or higher and with stated UVA/UVB protection on a daily basis with regular applications for the same period?(Required) Yes No Consent(Required) I agree to the privacy policy.I confirm that to the best of my knowledge that the information that I have supplied is correct and that there is no other medical information I need to disclose. I understand that treatments and products is not an exact science and therefore that no guarantee can be given as to the results of the treatment referred to in this document. I accept and understand that the goal of this treatment is improvement, not perfection, and that there is no guarantee that the anticipated results will be achieved.Signature(Required) Δ