Line Freezing Injections (B-tox)

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Today's Date:

Thu Jul 17 2025 05:42

Practitioner:*

****IMPORTANT COVID INFORMATION****

You MUST attend your appointment alone. No friends or family permitted, including children.
Minors (11-18 years) must be escorted by their PARENT, who will then wait at the studio door. (We're not a big place so you're literally a few paces away.)
PLEASE COME TO YOUR APPOINTMENT ON TIME, AND WAIT OUTSIDE TO BE COLLECTED. If you are early you will not be able to wait inside.
Clean face coverings MUST be worn at all times. If you forget yours we have them on sale for £3.
Please make a point of reading all signage on arrival for your safety. If you experience any symptoms prior to your appointment, please contact us to reschedule.

Please fill this form in to the best of your knowledge - it is here to keep you, and me safe at your appointment. Please complete it fully - failure in doing so may mean in the last minute cancellation of your precious appointment.

Please read and answer

Have you previously received any aesthetic treatments (eg. laser, peels, dermabrasion etc.) If yes please give details*

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Have you had any dermal filler treatment or botulinum toxin? If yes which treatment did you receive, what areas were treated and when?*

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Are you currently taking any dietary supplements or medications? If yes please note them here*

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Have you had any previous surgery?*

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Are you a smoker?*

If no, have you ever smoked?*

Do you drink alcohol? If yes, how many units a week?*

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Do you take regular exercise?*

Have you ever been admitted to hospital? If yes please give details*

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Do you have any allergies?*

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Have you suffered from any of the following?*

Heart disease/angina Thyroid problems Auto immune disease Arthritis Asthma/bronchitis Convulsions Depression High/low blood pressure Facial cold sores Diabetes Stomach ulcers Skin disease eg herpes or acne HIV/Hepatitis Glaucoma/cataract Venereal disease Bell's/facial palsy Phlebitis Hypoglycaemia

Are you pregnant or breast feeding?*

Have you a history of severe allergy/anaphylaxis ?*

Have you a history of severe allergy/anaphylaxis to Azzalure, Botox or it's excipients?*

Do you suffer from myasthenia gravis or Eaton Lambert syndrome?*

What areas are you interested in treating?*

Frown ('11' lines) Forehead (horizontal lines) Eyes (crows feet/laughter lines)

ADVISE CONSENT

I confirm that I have been informed that:

Line freezing injections are indicated for the temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at maximum
frown (glabellar lines); moderate to severe lateral canthal lines (crow’s feet lines) seen at maximum smile; moderate to severe crow’s feet lines seen at maximum smile and glabellar lines seen at maximum frown when treated simultaneously in adults, when the severity of these lines has an important psychological impact for the patient.
Like all medicines, line freezing injections can have side effects, although not everybody gets them. In general, side effects occur within the first few days following
injection. They usually last only for a short time, but they may last for several months and in rare cases, longer. These adverse reactions may be related to treatment, injection technique or both.
Diffusion of botulinum toxin into nearby muscles is possible when high doses are injected, particularly in the neck area.
As expected for any injection procedure, pain/burning/stinging, swelling and/or bruising may be associated with the injection. Speak to your doctor if you are worried about this.
Adverse reactions possibly related to the spread of toxin distant from the site of administration have been reported very rarely with botulinum toxin (e.g. muscle weakness, constipation, difficulty in swallowing, food or liquid accidentally going into the lungs which in some cases may lead to pneumonia). Injection are not recommended in patients with a history of dysphagia (difficulty to swallow) and impaired swallowing.
The chance of having a side effect is described by the following categories: Common - More than 1 out of 100 persons and less than 1 out of 10 persons.
Uncommon - More than 1 out of 1,000 persons and less than 1 out of 100 persons.
Injections in the forehead for vertical lines
Common side effects are: Headaches, drooping eye lid, skin redness, localised muscle weakness, face pain.
Uncommon side effects are: Infection, anxiety, numbness, dizziness, inflammation of the eyelid, eye pain, visual disturbance, nausea (feeling sick),
dry mouth, skin tightness, swelling (face, eyelid, around the eyes), sensitivity to light, itching, dry skin, muscle twitching, flu syndrome, lack of strength, fever.
Injections in the fan-shaped lines from the corner of the eyes Common side effects are: Swelling of the eyelid, injection site bleeding and/or bruising.
Uncommon side effects are: Injection site pain and/or tingling or numbness. Injections in the fan-shaped lines from the corner of the eyes, when treated at the same time as injections in the forehead for vertical lines
Common side effects are: Injection site bruising.
Uncommon side effects are: Injection site bleeding and/or pain. The following additional side effects have been reported for botulinum toxin since it has been marketed: allergic reactions, which can be serious (swelling of the
face and airways, difficulty in breathing), loss of nerve supply to/shrinkage of injected muscle, respiratory depression and/or respiratory failure, aspiration
pneumonia (lung inflammation caused by accidentally breathing in food, drink, saliva or vomit), chronic disease affecting the muscles (myasthenia gravis), blurred vision, difficulties in seeing clearly, slurred speech, strabismus (squint), numbness, tingling and pain in hands and feet, fainting, pain/numbness/ or weakness starting from the spine, drooping of the muscles on one side
of the face, weakness of the face muscles, difficulty moving the arm and shoulder, decreased skin sensation, muscle pain, abdominal pain, diarrhoea, vomiting, loss of appetite, dry mouth, feeling sick, fever, different types of
red blotchy skin rashes, feeling generally unwell, speech problems, itching,
excessive sweating, hair loss, loss of eyebrows, decreased hearing, noises
in the ear, feeling of dizziness or “spinning” (vertigo).
Allergic reactions, difficulties to swallow, speak or breathe, have been
reported rarely when botulinum toxin type A has been used for other
uses. Visit your doctor immediately if such signs develop after treatment.
If any of the side effects get serious, or if you notice any side effects
not listed in this leaflet, please tell your doctor or pharmacist.
We are fully supported by a licenced prescriber for your safety. We call on them to be absolutely sure this treatment is right for you.Too frequent or excessive dosing of BOTOX® may increase the risk
of antibodies in the blood which may lead to failure of treatment with
botulinum toxin when used for this and other conditions.
The aesthetic effects of b-tox last for an average of 3-4 months but
will vary depending on the condition of the skin, area treated, amount
of product injected, injection technique and lifestyle factors such as sun
exposure and smoking.
After treatment, please avoid extreme facial expressions, alcohol
consumption and applying make up for 12 hours. Please avoid extreme
sun exposure, UV light, freezing temperatures and saunas for 2 weeks
after treatment.

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

Client Information

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