Consent Form – Botulinum Toxin for Sweating

Dr Magnus Lynch

Important: This is an example of the consent form you will be asked to sign on the day of your procedure. You do not need to sign it before the procedure. Please read it carefully and let us know if you have any questions before the procedure.

Patient & Procedure Details

Patient full name

Date of birth / ID

Site(s) & procedure(s)

What is botulinum toxin?

Botulinum Toxin is a purified protein produced by the bacterium clostridium botulinum. It supresses sweating for up to 6 months (with wide variation between individuals) by temporarily disrupting nerve activity to muscles and sweat glands. It is commonly used in the underarm area (axilla) and can also be used to treat the palms, scalp, forehead and other areas.

Important information

Please read carefully and only sign the form if you agree to the following:-

Contraindications

I can confirm that I do not suffer from a neuromuscular disorder, I am not taking muscle relaxants, do not have active infection and I am not pregnant or breastfeeding.

Blood thinners

I have informed Dr Lynch if I am taking anticoagulant (blood thinning) medicine including Aspirin, Rivaroxaban, Edoxaban, Clopidogrel, Warfarin, Vitamin E or others.

Limitations

I understand that occasionally the treatment wears off very quickly or does not work at all.

Alternatives

I have considered alternatives to treatment including doing nothing, topical anti-perspirants, iontophoresis, tablets that suppress sweating, Miradry and surgical denervation and I have decided that at this time Botulinum toxin is the best option for me.

Outcome

I understand that the effects take up to a week to become apparent and that with all treatments the actual degree of improvement cannot be predicted or guaranteed. I understand that the effect of treatments is temporary and needs to be repeated every 3-6 months.

License

I am aware that treatments are “off label”, as licensed use does not cover all of the areas that are commonly treated.

Botulinum toxin injections have some important risks and it is important that you are aware of these when deciding whether the treatment is right for you.

Risks

Increased sweating elsewhere Reduction in sweating in one area can sometimes lead to increased sweating elsewhere "compensatory hyperhidrosis".
Infection There is a very small risk of bacterial or viral (e.g. herpes virus or shingles) infection.
Injection site reaction Any injection can cause a reaction at the site. This includes pain, inflammation, scarring, keloid scar formation, pins and needles, burning, decreased sensation / numbness, tenderness, itching, swelling, redness, haematoma, bleeding, bruising, muscle twitching, skin nodule formation, increased pigmentation, decreased pigmentation.
General Rarely you can have a reaction to the Botulinum toxin. This can include fainting, nausea, noises in the ear, tiredness, nasopharyngitis, bronchitis, influenza-like symptoms, blurred vision, headache.
Allergic reaction There is a very small risk of allergic (anaphylactic) reaction which can be serious or life threatening.
Bleeding, bruising, haemosiderin staining A small amount of bruising is common and usually will peak 1-2 days after the procedure. Rarely there can be more significant bruising. Very rarely brusing or bleeding under the surface of the skin can lead to iron deposition "haemosiderin" in the skin leaving a permanent area of pigmentation.
Arm weakness Botulinum toxin in the underarm area can rarely cause weakness of the arms or hands.
Hand weakness Botulinum toxin injections in the palms have a significant risk of causing some weakness of the hands. There is a very small risk with injections in the underarm area.
Weakness of the forehead, drooping of the forehead or facial assymetry This is a risk of botulinum toxin injections in the forehead or scalp.

Additional risks / discussion

Aftercare

I am aware of the following:-

I should not rub or massage the treated areas for at least 4 hours after treatment.
I should avoid consuming alcohol for 24 hours after treatment.
I should avoid exercise for 24 hours after treatment.
I should avoid hot showers and saunas etc for 24 hours after treatment.

Confirmation & consent

By signing below, I confirm that I have read the above information and had adequate time to decide about my care. I confirm the site(s) and procedure(s) and have had the opportunity to ask questions about the treatment and alternatives. I have been provided with aftercare instructions. I consent to the above procedure(s) and to photographs being taken for my confidential medical record.

Clinician signature

Dr Magnus Lynch

Patient signature

Patient / Parent / Guardian

This document is an electronic record of consent.