Form of consent (use only for 13-16 year olds)
Patient’s surname/family name..…………………………………………………………...
Patient’s first names .…………………………………………………………………….….
Date of birth ………………………………………………………………………………….
NHS number (or other identifier)……………………………………………………….…..
 Male
 Female
Name of procedure/treatment: Botox injection
Statement of health professional: (to be filled in by appropriate health professional.)
I have explained the procedure to the patient. In particular, I have explained:
Intended benefits: To aid relief of symptoms.
Serious or frequently occurring risks: Bleeding, bruising, pain, infection, swelling,
redness, headache, numbness, muscle paralysis, muscle weakness, lack of response,
need for recurrent treatment, brow or eyelid ptosis, dysphagia, loss of facial expression,
blood vessel or nerve damage, hypersensitivity, rash, dry eyes, malaise, flu like symptoms,
fatigue, nausea
I have also discussed any available alternative treatments (including no treatment) and
any particular concerns expressed by this patient.
The following leaflet has been provided ……………….…………………………………………
I consider the patient to have sufficient understanding and intelligence to enable him/her to
understand fully what is proposed. In my opinion the patient is competent based upon
his/her ability to believe, understand, retain and weigh up the information provided to
him/her and so reach a decision voluntarily
Signed:…….……………………………………
Date .. …………………….……….….
Name (PRINT) ………………………. ……….
Job title …….. ………………….…….
Statement of patient
I have read above and I agree to the procedure/course of treatment described on this form
Patient’s signature ……………………………
Date…………………………………...
Name (PRINT) ………………………………………………………………………………………
Confirmation of consent (to be completed by the health professional when the patient
attends for the procedure, if the patient has signed the form in advance)
Signed:…….……………………………………
Date .. …………………….…………..
Name (PRINT) ………………………. ……….
Job title …….. ………………….…….
Statement of interpreter (where appropriate)
I have interpreted the information above to the patient to the best of my ability and in a way
in which I believe s/he can understand.
Signed ………………………….………………
Date ………………..…………………
Name (PRINT) …………………..…………………………………………………………………..
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