Botox Medical History
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex
Please Select
MALE
FEMALE
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
How did you hear about our clinic?
Please select all that applies
Doctor's Referral
Type Doctor's Name
Patient Referral
Type Patient Name
Attended Seminar/ Trade Show
Type Seminar Date/Location
Others
Newspaper
Website/Google Search
Social Media Ads
Yellow Pages
Magazine
Walk-In
Other
Visit Reason
Please select all that apply
I am interested in:
Botox Therapeutic (Pain Headaches Migraine)
Botox Cosmetic
Wrinkle reduction
Cosmetic Fillers (for lips or deep lines)
Cosmetic dental smile makeover
Are you nervous about getting Botox?
Please Select
YES
NO
If yes, please tell us why?
Medical History
Do you or have you had any of the following? Please check if you have or had.
Do you or have you had any of the following? Please check if you have or had.
Are you allergic to any of the following?
Please list any past illnesses or surgeries:
Have you had “Botox” or “Derma Filler “treatments in the past? If yes, please specify.
Previous Botox Clinic
Date of last Botox visit
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What products are you currently using on your skin?
Have you ever been treated by an endocrinologist, dermatologist, plastic surgeon? If yes, please specify.
Are you currently pregnant, breast feeding or do you plan to become pregnant in the next year?
Please list all medications you are currently taking:
Patient Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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