Botulinum Toxin Type-A Sweat Reduction Consent Form
Prescription Medication
Botulinum Neurotoxin Type-A is a prescription medication that acts as an inhibitor of acetylcholine release and a neuromuscular blocking agent. It is prescribed to decrease a medical condition known as Primary Hyperhidrosis (excessive sweating unrelated to another medical condition or medication). Botulinum toxin type-A injections temporarily prevent acetylcholine, a neurotransmitter, from activating eccrine sweat glands (glands that produce water-based sweat) in a specific area. This can include sweating of the underarms, face, neck, back, thighs, palms and feet.
Lumière Medispa practitioners prescribe and use Allergan Botox® to treat Primary Hyperhidrosis of the underarms, face, neck, back, thighs, palms, and feet.
Treatment
In your Botulinum Neurotoxin Type-A treatment, a series of injections will be administered directly into the skin of the targeted area to reduce sweating.
Many patients find a topical anaesthetic helps reduce discomfort from the injection. A topical anaesthetic cream can be applied 30 minutes before treatment. You must arrive 30 minutes before your appointment if you wish for this to be applied. Please inform us if you have a known allergy to lidocaine.
The onset of treatment can take 2-14 days to take effect and will usually remain effective for 6-9 months. Very rarely, there can be little or no effect, which may be linked to the formation of your own antibodies to botulinum toxin. A follow-up appointment will be available 14 days post-treatment.
Alternative Treatments
Other treatments for reducing sweating include prescription antiperspirants, anti-hydrotic medications, surgery, and lasers. We do not provide these treatments at Lumiere Medispa, but you are welcome to explore these options with your GP.
Contraindications:
You cannot have a Botulinum Toxin Type-A sweat reduction treatment if:
You have a known hypersensitivity to Botulinum Neurotoxin Type-A, sucrose, human albumin or sodium chloride.
You have an active infection or inflammation near the intended treatment area.
You have generalised disorders of muscle activity/weakness, such as myasthenia gravis and Lambert-Eaton syndrome.
You suffer from any disorder that disturbs the interaction between nerves and muscles.
You think you could be pregnant, are pregnant, or are lactating or breastfeeding. There are no adequate and well-controlled studies of Botulinum Neurotoxin Type-A in pregnant or nursing women; therefore, safety cannot be guaranteed.
Cautions:
You need to tell your aesthetic practitioner if:
You are taking aminoglycoside antibiotics, such as gentamicin or spectinomycin.
You are taking tubocurarine-type muscle relaxants.
You are taking anti-malarial medications.
Material Risk (the level of significance you personally apply to the risks, side effects or complications of this treatment within your own circumstances):
As with any medical procedure, this treatment carries the risk of side effects or complications. Discuss these risks with your practitioner to fully comprehend their implications. Consider the risks in relation to your personal circumstances, including your health, lifestyle and career and decide if they are acceptable. If not, discuss alternatives or take more time to decide.
Associated Risks:
Injection Site Bruising, Pain, Swelling, Rash, Local Numbness. These symptoms are usually mild and last less than a week but can last longer. Patients who are using medications that can prolong bleeding, such as aspirin, warfarin, or certain vitamins and supplements, may experience increased bruising or bleeding at the injection site.
Headaches are possible and usually last one day but may persist longer in a very small percentage of patients.
Infection. As with any procedure that involves a break to the skin’s surface, there is a risk that an injection of any material carries the risk of infection.
Hypersensitivity. Most medications carry a potential risk of allergic reactions. Allergic reactions have been reported with Botulinum Neurotoxin Type-A products, such as anaphylaxis, serum sickness, skin itching, skin swelling, and difficulty breathing. You should contact your practitioner if you feel unwell or have had an allergic reaction. You should seek immediate emergency medical care in cases of a severe allergic reaction (anaphylaxis).
Localised muscle weakness. Botulinum Toxin Type-A could exert its effect on local muscle tissue, such as those located in the shoulder and underarm, facial muscles controlling expression, or hand/foot movement.
Other very rare side effects include:
Little to no effect. Very rarely, botulinum toxin may not reduce or reduce sweating as intended. This should be discussed with your practitioner at your earliest convenience. Whilst we will endeavour to increase the effect for you, there is no guarantee it will be effective, and no refunds will be given in this case.
Nausea
Anxiety
Dry mouth
Altered skin sensation, muscle twitching or spasm in the treated area.
Fever
Lack of strength
Flu-like symptoms
Itching or dry skin
Muscles weakness. Do not drive or operate heavy machinery if you experience muscle weakness, and contact your practitioner immediately.
Rash
Swallowing and Breathing Difficulties. Treatment with Botulinum Neurotoxin Type-A products can very rarely result in swallowing or breathing difficulties. Patients with pre-existing swallowing or breathing difficulties may be more susceptible to these complications. These reactions can occur hours to weeks after injection with Botulinum Neurotoxin Type-A.
Seek immediate medical care if swallowing, speech, or breathing difficulties arise.
This consent form is not meant to include all possible risks associated with a Botulinum Toxin Type-A sweat reduction treatment, as known and unknown side effects and complications are associated with any medical treatment. We have written this consent form to ensure you are fully informed of the procedure, reasons why you may not be able to receive treatment and known risks of a Botulinum Toxin Type-A sweat reduction treatment.
Photographs:
We need to take photos of the treatment area to document the original condition before treatment begins and to monitor results and potential changes throughout the treatment process. These photos will become part of your medical aesthetic treatment record at Lumiere Medispa.
You have the right to refuse consent for these photographs. However, please be aware that without this consent, we will not be able to treat you for medico-legal reasons.
If we wish to use your photos for any other purpose, we will always seek separate written consent from you. You have the right to refuse this additional use of your photos, and it is not mandatory to consent to any other photo usage to receive treatment.
By signing this consent form, you acknowledge and confirm the following:
Risks and complications
You have discussed the potential risks and benefits of a Botulinum Toxin Type-A sweat reduction treatment with your practitioner, and all of your questions have been answered to your satisfaction.
You understand that medical attention may be required to resolve any complications associated with your treatment. In most cases, except those in an emergency, you should contact your practitioner for advice/treatment.
Medical History
To the best of your knowledge, you have provided the details of your past medical history and will inform your practitioner if this changes before any future treatments.
You understand that withholding aspects of your medical history could lead to serious physical and mental harm.
Contraindications & Cautions
You are not pregnant or possibly pregnant, lactating or nursing, and you will inform your practitioner if this changes before any future treatments.
Fees & Charges
You understand and agree that all services rendered will be charged directly to you, and you are personally responsible for payment.
You further agree, in the event of non-payment, to bear the cost of collection, court costs and reasonable legal fees, should they be required.
Refunds
Fees charged for treatment are for the delivery of a treatment and the accompanying service, which is inclusive of the following;
-Consultation and assessment
-The provision of information and advice
-The provision of the treatment itself, as described above
-Follow-up appointments and aftercare advice and support as appropriate
Whilst we undertake to provide excellent service, factual, honest and ethical advice, safe, expert treatment in experienced hands and only the best products, we cannot guarantee your results and cannot offer refunds if the results achieved fail to meet your expectations. The successful outcome varies by degree, and how long these effects last varies from one individual to another and cannot be guaranteed.
You understand that whilst you have been advised of a probable result, this should not be interpreted as a guarantee.
You will contact your practitioner if you are unsatisfied with your treatment outcomes.
Aftercare
You have verbally discussed the aftercare required following a Botulinum Toxin Type-A sweat reduction treatment, and you have been informed that you will also receive this via email. You understand the importance of following the post-treatment advice and agree to follow it.
You understand that failure to follow this advice could lead to serious physical and mental harm.
Photograph Use Consent:
You understand that receiving treatment at Lumiere Medispa requires photographs to be taken of the treatment area. These photographs may be taken before, during, and after each treatment and will form part of your legal medical record at Lumiere Medispa. By signing below, you freely give your consent for your photos to be used solely for this medico-legal purpose. If we wish to use your photos for any other purpose, we will always seek separate written consent from you, and you have the right to refuse.
Valid Consent
By signing below, you acknowledge that you have read and understood this consent form and have had the opportunity to discuss any questions you have with your practitioner to your satisfaction. You consent to receive a Botulinum Toxin Type-A sweat reduction treatment under the terms of this consent form and understand that you have the right not to consent to this treatment and that your consent is voluntary.
