Anti-wrinkle (botulinum toxin) consent form template (UK)

This template is for UK aesthetics practitioners administering botulinum toxin (Botox, Bocouture, Azzalure and equivalents). A consent form only protects you if it is defensible: the consent must be informed (the patient saw the real risks in writing), specific (this treatment, these areas, this product), signed by both parties, versioned (you can show which wording the patient signed on that date), and retrievable years later when an insurer or solicitor asks for it. A generic tick-box sheet that lives in a filing cabinet fails most of those tests.

Why each section exists

Insurers expect to see evidence that risks were disclosed before treatment, not summarised afterwards. That is why the risk acknowledgements sit above the signature and are itemised rather than rolled into one line: a patient who initials or ticks each risk cannot credibly claim the conversation never happened. The exclusion questions (pregnancy, breastfeeding, neuromuscular conditions) are there because botulinum toxin is contraindicated in those groups, and a signed answer protects the practitioner who relied on it.

The direction of travel in England matters too. The government has confirmed plans for a licensing scheme for non-surgical cosmetic procedures, and consultation documents consistently point towards written, auditable consent and record-keeping standards. Practitioners who can already produce versioned, dated, signed consent for every treatment will have nothing to retrofit.

Finally, the practitioner counter-signature is not decoration. It records that you, personally, discussed the procedure, the benefits, the risks and the alternatives. If consent is ever challenged, the document shows a two-sided conversation rather than a form pushed across a desk.

The template

Patient details

Full name: ___________________________

Date of birth: ___________________________

Phone: ___________________________

Email: ___________________________

Address: ___________________________

Treatment details

Product (e.g. Botox, Bocouture, Azzalure): ___________________________

Areas to be treated: ___________________________

Date of treatment: ___________________________

About this treatment

Botulinum toxin type A is a prescription-only medicine injected in small doses to relax targeted facial muscles, softening dynamic lines. The effect typically develops over 3 to 14 days and lasts around 3 to 4 months, after which movement returns gradually. Results vary between individuals and no specific outcome can be guaranteed.

Exclusions and screening

Please confirm each of the following:

• I am not pregnant and not trying to become pregnant
• I am not breastfeeding
• I do not have a neuromuscular condition (for example myasthenia gravis, Eaton-Lambert syndrome, motor neurone disease)
• I am not allergic to botulinum toxin or any of its constituents (including human albumin)
• I do not have an active skin infection at the treatment site
• I have disclosed all medication I take, including blood-thinning medicines and supplements

Risk acknowledgement

I understand and accept the following recognised risks of botulinum toxin treatment:

• Bruising, redness and swelling at the injection sites
• Headache in the days after treatment
• Asymmetry of result, which may require review or adjustment
• Eyelid or brow ptosis (drooping), which is usually temporary but may last weeks
• Under- or over-correction, including a heavy or frozen feeling
• Rarely, spread of toxin effect beyond the treated area, causing muscle weakness, swallowing or breathing difficulties; I will seek medical attention urgently if these occur
• Allergic reaction, which is rare

Pre- and post-treatment notes

• I understand that alcohol, aspirin, ibuprofen and other blood-thinning medicines or supplements taken in the days before treatment increase the risk of bruising. I have not stopped any prescribed medication without medical advice.
• I have received and understood the aftercare instructions, including remaining upright for 4 hours, not rubbing the treated area, and avoiding strenuous exercise and alcohol for 24 hours.

Photography

• I consent to clinical photographs being taken before and after treatment for my confidential patient record.
• I additionally consent to my photographs being used for marketing purposes (optional).

Outcome, review and top-up policy

• I understand that results cannot be guaranteed and that individual response varies.
• I understand the clinic’s review policy: a review appointment is offered at 2 to 3 weeks, and any adjustment or top-up is at the prescriber’s discretion within that window. Requests outside the review window may be charged as a new treatment.

Patient declaration

I confirm that I have read and understood the information above, that I have had the opportunity to ask questions and that they have been answered to my satisfaction. I confirm that the information I have given is true and complete, and I consent to treatment with botulinum toxin as described.

Patient signature: ___________________________

Print name: ___________________________

Date: ___________________________

Practitioner declaration

I confirm that I have explained this procedure to the patient, including its intended benefits and material risks, and any available alternative treatments, and that the patient has had the opportunity to ask questions.

Practitioner signature: ___________________________

Print name and qualification: ___________________________

Date: ___________________________

Using it in practice

You can copy this template into your own document, add your clinic name, logo and prescriber details, and print it for in-clinic signing. If you adapt the wording, date the version so you always know which text a given patient signed, and keep superseded versions on file. Pair it with a completed medical history form before every first treatment, and record what was actually injected on a treatment record with batch numbers.

AesthetiClinic handles the unglamorous part for you: it sends this form e-signed to the patient’s phone before the appointment, versions the wording every time you change it, and files the signed copy on the patient record automatically. See how the forms engine works.

After treatment, point patients at your written aftercare. A solid starting point is our anti-wrinkle aftercare guide. You can browse every free document in the template library.

This template is provided as a starting point for UK aesthetics practice. It is not legal or medical advice. Review the wording with your insurer and, where relevant, your prescriber before use.