Muscle relaxant TREATMENT FORM

Name: …………………………………………………………………………………………..

Have you had botox/disport/xeomine previously?            Yes  –              No  –

Are you pregnant or breastfeeding?                                     Yes  –              No  –

Are you taking any Aminoglycoside antibiotics?                 Yes  –              No  –

Do you have Myasthenia gravis?                                           Yes  –              No  –

Have you any allergies?  (list)

…………………………………………………………………………………………………

Muscle relaxant CONSENT FORM

I, …………………………………………………………….

Hereby consent to the procedure of muscle relaxant (botox/disport/xeomine) treatment to be carried out on myself.

I have been informed regarding the treatment and procedure, indications, expected results and possible side effects.     YES  –   NO   –  

I had the opportunity to have questions answered to my satisfaction.     YES  –   NO   –  

I have been given and read the patient information sheet    YES  –   NO   –  

I agree that this procedure is being carried out for cosmetic reasons and no guarantee of any nature can be made as to the result of the procedure.  I accept that while every precaution will be taken to prevent complications and that while complications from the procedure are rare they can and sometimes do occur.

I am undergoing this treatment of my own free will.  I accept responsibility for any complications and thereby absolve VISTA Clinic Australia Pty LTD and the doctor and any other associated persons of any blame resulting therefrom.

Patent signature:            …………………………………..  Date: ………………….

Practitioner signature:    …………………………………..  Date: ………………….