Medical History and Consent Form

Please note that this medical consent form will be kept confidential and will only be viewed by the Doctor responsible for you whilst undergoing treatment at this Cosmetic Injectables clinic. Your details will not be available to third parties.

If any of the answers on this consent form raise a concern for the cosmetic injectables practitioner responsible for your safety, you may be contacted to discuss further or these may be discussed at the time of your consultation. We won’t share your details with anyone not directly involved in the running of this clinic.

Patient Details
Medical History

Are you attending or receiving treatment from a doctor or specialist?

Are you taking any medication, or herbal remedies (including Antibiotics, Anticoagulants, Muscle Relaxants, St. Johns Wart, Roaccutane)?

Are you taking blood thinning medication (Aspirin, Plavix, Warfarin)?

Are you allergic to local anaesthetic injections, lignocaine, adrenaline or EMLA/ANESTOP/LMX4 cream?

Do you have any known allergies or a history of anaphylaxis?

Have you suffered from or had any of the following conditions?

Heart problems including an irregular heartbeat or angina

High or Low Blood Pressure or circulation problems including Raynaud’s Syndrome


Blood disorders/leukaemia/lymphoma/anaemia/cancer

Autoimmune disease, arthritis or recurrent sore throat.


Contact Dermatitis/Eczema

Keloids (hypertrophic scarring) or recent scar tissue (6 months) This is more common in dark-skinned individuals. See here for a picture

Easy bruising

Cold Sores

Psychiatric Illness/Depression

Do you use sunbeds or sunbathe?

Do you play a woodwind or brass instrument? (Because Botulinum Toxin softens wrinkles through its effect on muscles, it is important that you avoid treatment with Botulinum Toxin around the mouth if you play either of these families of instruments).

Are you pregnant/planning pregnancy/engaged in IVF treatment or are you breast-feeding?

Have you had a consultation or been treated with dermal filler, Botulinum Toxin, laser, chemical peels or microderm abraision before?

Have you had an allergic reaction to any dermal filler or Botulinum Toxin product?

Have you had a consultation or had plastic surgery of the face or neck or are you planning to have surgery?


Before and after photos are always taken to help assess treatment — these are confidential. However, I give my written consent for my photos to be used to show to future patients, and for marketing purposes.


See our photo gallery

I hereby consent to the following:

I have no known allergy to local anaesthetic cream or injections and understand that either or both may be required as part of my treatment.

I have been informed about the risks and possible side effects of treatment and accept these risks as my own. I have understood and correctly completed the medical history form.

An undesired cosmetic effect, such as an unexpected appearance after treatment, can usually be avoided by clear communication between patient and Healthcare Professional.

Please sign your name inside the blue box

By submitting this form you are consenting to store your data privately on our system. Your private data will be held in accordance with data protection regulations.

Sculptra is a collagen stimulator used for facial cosmetics. The Sculptra product itself is not providing the filling action but instead causes a reaction in the skin, which forms new collagen. Depending on the area treated, skin type and injection technique the effect of Sculptra lasts approximately 2 years after the last treatment. Sculptra requires a series of treatments to achieve adequate filling for most skin defects. You should discuss your treatment plan fully with your Healthcare Provider before beginning treatment.

Sculptra is injected under the skin in the area to be treated (usually the face) using several injections per area. These injections are mildly painful. The treated areas will be mildly sore for up to 3 days after treatment. Your skin will be deeply massaged/manipulated by the doctor after treatment. You may resume normal activity immediately.

Your skin may appear "lumpy" and mildly red or swollen for 24 to 48 hours after the treatment. This is normal. There may be mild bruising of the skin, especially if treatment is around the eyes, which may last for up to 7 days. If swelling is severe, pain or bruising is increasing, or fever develops, call the clinic where your Sculptra was administered. You will have puffiness (not severe) for up to 10 days after the procedure. This is simply the water used to carry the Sculptra product into your skin, and most of this is reabsorbed within the first week.

The effect of Sculptra is slow and gradual as your skin forms collagen around the product crystals. Your best results are seen about 3 months after your last treatment. Please be patient!

Other possible adverse events:

  • Temporary numbness or tingling in the treated area.
  • Temporary partial facial muscle paralysis (from the lidocaine anesthetic), lasting less than 2 hours.
  • Infection at the injection sites. This would be very rare and treated with routine antibiotics.
  • Small "bumps" rarely (~1%) form deep in the skin in the treated areas, which may or may not become visually apparent. This represents new collagen, which has formed deep in the skin.

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Botulinum Toxin (commonly referred to as the brand name ‘Botox’) is a purified bacterial toxin used worldwide for the reduction of facial wrinkles.

The time period before the Botulinum Toxin treatment is effective is 2-14 days. The treatment will last between 3-9 months.

Potential complications and side effects of Botulinum Toxin include:

  • Ptosis (eyebrow and/or eyelid) — especially if treating forehead.
  • Unwanted arching of the eyebrows if treating crows feet/forehead but especially frown lines.
  • Bruising and swelling at site of injection or a black eye.
  • Treatment may not work — everyone is different. Rarely, wrinkles can become worse.
  • Migraine, Temporary double vision, possible temporary numbness.

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Dermal Filler is the synthetic form of a natural substance found in human tissues (Hyaluronic Acid ). It can be injected directly beneath the skin to provide cosmetic benefits. It is effective immediately and can last from 6-12 months.

After treatment, you are advised to avoid wearing makeup over the injection sites for 12 hours to reduce the risk of skin infection.

Potential complications and side-effects of filler include:

  • Bruising, bleeding, discomfort, itching for several days.
  • Rarely discolouration of the injection site, necrosis (death of skin), abscess formation, granulomas (abnormal growth of skin), hypersensitivity and haematomas (large bruises) have been reported. Indurations or nodules may develop at the injection site — if any of these symptoms persist for more than 1 week, consult with the doctor/dentist/nurse who has treated you.
  • When using dermal filler to treat frown lines, smile lines (nasolabials / nose-mouth lines) there is a very small risk of skin damage requiring plastic surgery or even irreversible blindness. Feel free to ask your practitioner what precautions they will take to minimise this risk.

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