BOTOX CONSENT FORM

Treatment Details

This consent form pertains to the use of Botox (Botulinum toxin Type A), a prescription-only medication regulated by the Therapeutic Goods Administration (TGA) in Australia.

At Mojo Cosmetic Clinic, only licensed medical practitioners administer Botox treatments.

Brand(s) Used: Botox by Allergan (Alternative brands such as Dysport or Xeomin will be disclosed if used).

How Botox Works

Botox temporarily relaxes targeted muscles by blocking nerve signals, reducing wrinkles and fine lines. Results typically appear within 2–7 days and peak around 14 days. The effects generally last 3–5 months but may vary based on individual factors such as metabolism, lifestyle, and treatment area.

Potential Risks and Side Effects

While Botox is widely regarded as safe, potential risks include:

Common Risks:

  • Minor redness, swelling, or bruising at the injection site (2–7 days).
  • Temporary discomfort or mild pain during injections.
  • Transient headaches or flu-like symptoms.

Less Common Risks:

  • Eyelid or eyebrow drooping (ptosis).
  • Asymmetry in results or lack of effect (treatment failure).
  • Dry eyes or excessive tearing when treating areas near the eyes.
  • Temporary weakness in unintended areas due to migration of the product.

Rare Risks:

  • Dysphagia (difficulty swallowing) or difficulty speaking.
  • Allergic reactions, including rash, itching, or breathing difficulties (seek emergency medical care if this occurs).
  • Persistent swelling or infection at the injection site.
Contraindications

You should not undergo Botox treatment if you:

  • Are pregnant, breastfeeding, or planning to become pregnant.
  • Have a known allergy to Botox, Botulinum toxin, or any of its components (e.g., human albumin).
  • Have a history of neuromuscular disorders (e.g., Myasthenia Gravis, ALS).
  • Are currently taking aminoglycoside antibiotics or other medications that may interact with Botox.
Post-Treatment Care

To ensure optimal results and minimise complications:

  • Avoid lying down or bending over for at least 4 hours after treatment.
  • Refrain from strenuous exercise, alcohol consumption, and excessive sun exposure for 24 hours.
  • Do not massage or rub the treated area for at least 24 hours.

If you experience any unexpected symptoms or have concerns, please contact Mojo Cosmetic Clinic immediately.

Privacy and Data Handling

Mojo Cosmetic Clinic complies with the Australian Privacy Principles (APP). Your personal and medical information will be handled securely and used only for your care and as required by law. For more details, refer to our Privacy Policy available on our website.

Acknowledgements and Consent

Please read and tick each box to confirm your understanding:

I understand the nature, purpose, and expected outcomes of Botox treatment.

I acknowledge that results may vary and multiple treatments may be required.

I am aware of the potential risks and side effects, and I accept these risks.

I confirm that I have disclosed my full medical history, including any allergies, medications, or contraindications.

I consent to the collection and storage of my personal and medical information as per the Australian Privacy Principles.

I understand I can withdraw consent at any time prior to treatment.

By signing below, I confirm that I have had sufficient opportunity to ask questions and that all my questions have been answered to my satisfaction. I voluntarily consent to Botox treatment as outlined above.

Draw your signature using your fingers or mouse in the box below

Please click on the Tick icon() to verify your signature. After that you can submit the form.