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: ………………….

 

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Get In Touch

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CONTACT

Email: me@vistaclinic.com.au

Phone: + 61 (0) 434 780 777 

Fax: +61 (03) 9978 9484

Business Hours:  By appointment. Monday, Thursday, Friday, Saturday. 

Flexible hours, including Sundays and holidays - for VIP.

Address: Suit 415, Level 4,

The Exchange Tower

530 Little Collins St  Melbourne 3000 VIC Australia

Main Entrance to the Exchange Tower from the Little Collins St or via coffee shops lane, then via lifts - to level 4.

* Melbourne architects have sense of humor! - 530 Collins and 530 Little Collins are across the road - you need a Little Collins one with the sign "The exchange Tower"

Chocolates/spring water and comfortable chairs on a waiting area.

We are flexible with hours for our regular loyal patients - please, contact reception or book appointment while at the practice.

Looking forward to see you!