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Consent and consultation form for patients treated with ...

Consent and consultation form for patients treated with BOTOX (Botulinum Toxin Type A)Name: Address: Postcode: Home Tel: Mobile: Email: Date of birth: BOTOX (Botulinum Toxin Type A) Treatment recordPrescribing information can be found at the end of this document Medical historyPlease complete the following medical questionnaireHave you previously received any aesthetic treatments ( laser, peels, dermabrasion etc.) YNIf yes, please give more details Have you had any dermal filler treatment or botulinum toxin? YNIf yes, which treatment did you receive, what areas were treated and when? Do you smoke? How many per day? If No , have you ever smoked? YNWhen did you give up? Do you drink alcohol?

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

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  Form, Myasthenia, Gravis, Myasthenia gravis

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