Dysport Pre-Treatment Checklist

Consultation date(Required)

Patient Info

Name(Required)

First Last

Phone(Required)

Email(Required)

D.O.B(Required)

Checklist

Do you have any medical conditions that you are aware of (past or present)?(Required)

Yes

Please provide details(Required)

Are you currently undergoing investigations for any medical conditions?(Required)

Yes

Please provide details(Required)

Please list any medications, vitamin and/or mineral supplements you are taking(Required)

Some medicines (muscle relaxants, aminoglycoside antibiotics, penicillamine, procainamide, spectinomycin, polymixins, tetracylines and lincomycin) can interfere with the way Dysport works, and some vitamin/mineral supplements can thin your blood causing an increased risk of bruising. It is important that you tell your cosmetic practitioner, prior to treatment with Dysport, if you are taking any medicines, vitamin and/or mineral supplements.

Have you been diagnosed with Myasthenia Gravis or Eaton‑Lambert (myasthenic) syndrome?(Required)

These are both autoimmune diseases that cause muscle weakness.

Yes

Have you ever had prolonged periods of muscle weakness?(Required)

Yes

Do you have a history of prolonged bleeding times?(Required)

Yes

Are you pregnant/breast feeding or planning to become pregnant?(Required)

Dysport has not been tested in these situations, and is not recommended.

Yes

Do you have any allergies to food or medicines?(Required)

Yes

Have you had a previous reaction to botulinum toxin, or to any ingredients contained in botulinum toxin?(Required)

Clostridium Botulinum Type A Toxin – Haemagglutinin Complex, 125 microgram human serum albumin and 2.5 mg lactose in a sterile, lyophilised form without a preservative

Yes

Do you have any difficulties in swallowing?(Required)

Yes

Do you have any difficulties breathing?(Required)

Yes

Do you have any signs or symptoms of inflammation or infection in the area to be treated?(Required)

Yes

Please provide details(Required)

Have you had facial surgery?(Required)

Yes

Please list details and approximate year of surgery(Required)

Have you had treatment with Dysport or another brand of botulinum toxin in the last 3 months?(Required)

Yes

Please provide details(Required)

Have you received any facial cosmetic procedures recently?(Required)

Yes

Provide details including date of procedure(Required)

Patient Consent

Important information as discussed with your cosmetic practitioner

Dysport contains Botulinum Toxin Type A, a muscle relaxant which acts on the junctions between the nerves and muscles thereby preventing or helping to reduce the muscles in the treated area from contracting. Once the muscles are relaxed, the overlying wrinkles will soften or reduce.

Dysport contains a small amount of albumin that has been obtained from human blood. The risk of a viral infection is rare but cannot be eliminated completely when using human blood or products made from human blood.

The effects of Dysport usually occur within 2–3 days post-injection but it may take up to 21 days for the peak effect to occur, with the duration of effect lasting 5 months or more. The effects may vary from person to person. Treatment effects are temporary and retreatment is necessary to maintain the results.

The most frequent side effects reported after treatment are headache and injection site reactions, including discomfort, burning, redness, and bruising. Other side effects may include local muscle weakness, including temporary drooping of the eyelids or eyebrows along with swelling of the eyelids, double vision, dry eyes, pins and needles or numbness, and nausea or flu-like symptoms. If you experience any of these unwanted side effects, you should consult your cosmetic practitioner.

Dysport is not recommended for pregnant or breast-feeding women or for those intending to become pregnant or breast-feed. There are some medicines that can interfere with the way Dysport works, therefore, it is important to tell your treating cosmetic practitioner about all the medicines you are taking, including any that you buy without prescription from your pharmacy, supermarket, or health food shop. Dysport must not be given to patients who have had a previous allergic reaction to Botulinum Toxin Type A or are allergic to any ingredients in Dysport; any patient with a medical condition of a neuro-muscular type such as myasthenia gravis and certain neurological disorders; or if there is any sign of infection at the proposed injection site.

Treatment Consent(Required)

I understand that this form will be retained in my medical records.
For information on the clinic/practice privacy policy please ask the treating cosmetic practitioner.

I confirm that I have had a consultation prior to treatment with Dysport and have been informed
regarding the treatment and procedure, indications, expected results and possible side effects. I have read the Dysport Consumer Medicine Information and have had any questions relating to the treatment answered to my satisfaction. I confirm that I have fully disclosed details of previous treatments and my full medical history during consultation.

In particular, I confirm that I have informed my cosmetic practitioner if:
• I am pregnant or intend to become pregnant, or if I am breastfeeding or plan to start breastfeeding
• I am taking any blood thinning medication
• I have had any previous allergic reaction to Botulinum Toxin Type A or I am allergic to any ingredients in Dysport (Clostridium Botulinum Type A Toxin – Haemagglutinin Complex, 125 microgram human serum
albumin and 2.5 mg lactose in a sterile, lyophilised form without a preservative)
• I have any neuromuscular conditions including myasthenia gravis or myasthenic syndrome
• I am aware of any potential infection at the proposed injection sites
• I am taking any other medications, including non-prescription medications or food supplements

I am having this treatment for cosmetic reasons and understand that results may vary from person to person.

I agree to follow the aftercare instructions provided by my cosmetic practitioner and understand that follow-up at two weeks is generally recommended. I have been informed and understand that further treatments will be required to maintain the effects, as the treatment results are temporary.

I understand that I am paying for a treatment and not a guaranteed result as individual results may vary; and I accept that retreatment, if required, will be at my expense.

I confirm

Image Consent(Required)

I grant the clinic permission to:

Take photographs, recordings, and/or video footage of me before, during, and/or after the treatment.
Use my voice, image, likeness, and statements for any purpose, including (but not limited to):

Promotional, advertising, and publicity purposes, including the use of photographs, recordings, or video footage of me, where permissible, in any promotional, advertising, or marketing materials on the clinic website, social media sites, and within printed materials.
Use in any clinic promotional materials.
Use in educational materials, including videos, recordings, and printed materials, without separate remuneration or compensation, for an unlimited time.

I acknowledge and agree that the clinic owns all proprietary rights, including all intellectual property rights, in any photographs, recordings, or video footage taken of me in connection with the treatment that contain my voice, image, likeness, or statements.

I have read and fully understand the above and have had sufficient opportunity to discuss with and ask questions with my cosmetic practitioner.

I request and consent to treatment with Dysport.

Yes

Name(Required)

First Last

Date

Signature(Required)

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Dysport Pre-Treatment Checklist

Patient Info

Checklist

Patient Consent

Important information as discussed with your cosmetic practitioner

Great results speak for themselves

Get in touch

Consent Forms

Dysport Pre-Treatment Checklist

Patient Info

Checklist

Patient Consent

Important information as discussed with your cosmetic practitioner

Great results speak for themselves

Get in touch

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