Botox Medical History Form

    Please answer all questions.



    Medical History

    Please complete the following medical questionnaire


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    If the answer is yes to any of the above, your medical practitioner may ask for further details. Treatment may be refused if it is not considered in your own interest to proceed.

    Advised consent

    I confirm I have been informed that:

    The products in the VYCROSS® Collection (JUVÉDERM® VOLUMA® with lidocaine, JUVÉDERM® VOLIFT® with lidocaine, JUVÉDERM® VOLIFT® Retouch® with lidocaine, JUVÉDERM® VOLBELLA® with lidocaine, JUVÉDERM® VOLITE® with lidocaine), are a non-animal, hyaluronic acid -based (sugar-based), non-permanent transparent gel which is injected to:

    • Restore facial volume (JUVÉDERM® VOLUNIA® with lidocaine)

    • Treat deep skin depressions, face contouring and volume restoration (JUVÉDERM® VOLIFT® with lidocaine, JUVÉDERM® VOLIFT® Retouch® with lidocaine)

    • Treat fine lines and medium-sized skin depressions as well as enhancement and pouting of the lips (JUVÉDERM® VOLBELLA® with lidocaine)

    • Treat line fines and for additional improvement of skin quality attributes such as hydration and elasticity (JUVÉDERM® VOLITE® with lidocaine)

    Treatment with JUVÉDERM® VOLUMA® with lidocaine may remain effective for up to 18 months¹; treatment with JUVÉDERM® VOLIFT®, VOLIFT® Retouch® and VOLBELLA®' with lidocaine for up to 12 months²³; treatment with JUVÉDERM® VOLITE® with lidocaine is proven to improve dermal hydration for up to 9 months⁴. This will vary depending on the skin type, areas treated, quantity of product injected, the injection technique and lifestyle factors such as sun exposure and smoking.

    A touch up session may be recommended a few weeks after the first session to increase the effects and maximize the results. You should be made aware that the products contain O.3% lidocaine (HCl) which may produce a positive result in anti-doping tests.

    After an injection with either one, two, three, four or five of the VYCROSS® Collection products, inflammatory skin reactions (for example, redness, swelling, rash), which may be accompanied by itchiness or pain on application of pressure, may occur. These reactions may last up to a week. Bruising, lumps or nodules may appear at the injection site. Very rarely, cases of discoloration or lightening at the injection area have been reported. Rare cases of necrosis (cell death), abscesses collection of pus), granulomas (foreign body reaction) and immediate or delayed hypersensitivity (allergic reactions) have also been reported after hyaluronic acid injections and/or lidocaine, as have poor or weak filling effects.

    After treatment, please avoid extreme facial expressions, alcohol consumption and applying make up for 12 hours. Please avoid extreme sun exposure, UV light, temperatures below O°C, saunas and steam rooms for 2 weeks after treatment. It is advisable to avoid strenuous activity or exercise for up to 24 hours and to avoid massaging the treated area. Try to sleep with the head elevated and avoid sleeping on the injected areas for one or two days.

    The use, indications, contraindications (specific situations in which the five VYCROSS® Collection products: JUVÉDERM® VOLUMA® with lidocaine, JUVÉDERM® VOLIFT® with lidocaine, JUVÉDERM® VOLIFT® Retouch® with lidocaine, JUVÉDERM® VOLBELLA® with lidocaine, JUVÉDERM® VOLITE® with lidocaine, should not be used) and the possible side effects have been explained to me. There are specific situations in which one, two, three, four or five VYCROSS® Collection* products should not be used, these can be identified from my medical history. I have accurately and truthfully answered all the questions regarding my precious medical and aesthetic treatment history to the best of my knowledge.

    I was given the opportunity to ask questions and I am satisfied with the answers given.

    If inflammatory reactions persist for more than one week, or if any other side effects appear, I will inform my medical practitioner who will treat appropriately. Whilst rare, such side effects may require treatment lasting several months before they disappear.

    On Voluntary undertaken basis:

    I am interested in speaking to the media about my experience with products from the VYCROSSL Collection* and my medical practitioner can provide more information about this. (Please tick appropriate box)

    I agreeI disagree

    My medical practitioner may use pictures taken before and after my treatment for the following purposes. I have seen these pictures and agree or disagree with their use as follows (Please tick the appropriate boxes):


    I agreeI disagree


    I agreeI disagree

    *The VYCROSS® Collection = either one, two, three, four or five of the following products JUVÉDERM® VOLUMA® with lidocaine, JUVÉDERM® VOLIFT® with lidocaine, JUVÉDERM® VOLIFT® Retouch® with lidocaine, JUVÉDERM® VOLBELLA® with lidocaine, JUVÉDERM® VOLITE® with lidocaine.

    I have read and understood the post-injection recommendations and undertake to observe them.