CONSENT TO BOTULINUM TOXIN A TREATMENT

Consent to Botulinum Toxin A Treatment
Botox, Xeomin, Dysport
Important Information
Botulinum Toxin A (BOTOX, XEOMIN, DYSPORT), a neurotoxin produced by the bacteruim Clostridium A. Botulinum Toxin A can relax the muscles on area of the face and neck which cause your facial expression lines or wrinkles to essentially disappear. Botulinum Toxin A diluted to a very controlled solution and when injected into the muscle with a very thin needle, it is almost painless. Patients may feel a slight burning sensation while the solution is being injected. The procedure takes about 15-20 minutes and the results last 3-6 months. With repeated treatments, the results may tend to last longer.
Patient Information
Patient Name
First NameLast Name
Age
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Email Address
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Phone Number
Area CodePhone Number
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Medical Health Data

Please answer the following:

Rows	Yes/No	Description/Remarks
Have you been treated for any dermal issues before?
Is this your first time receiving Botulinum Toxin A (Botox, Xeomin, Dysport) treatment?
Have you been diagnosed with Bleeding Disorder?
Have you been diagnosed with Pigmentation Disorder?
Have you been diagnosed with HIV/AIDS?
Have you been diagnosed with Cancerr?
Have you been diagnosed with Neuromuscular Disorder including but not limited to Myasthenia Gravis, Multiple Sclerosis, Lambert-Eaton Syndrome, Amyotrophic Lateral Sclerosis (ALS), Parkinson’s. ?
Have you been diagnosed with Psychiatric Illness?
Have you been diagnosed with Heart Disease?
Have you been diagnosed with Liver Disease?
Have you been diagnosed with Respiratory Illness(Lung Disease, Asthma, Shortness of Breath?
Do you have history of Keloid Scarring?
Do you have Migraines?
Do you have High Blood Pressure?
Do you have Chronic Fatigue?
Do you have Hepres or Cold Sores?
Do you have history of Epilepsy or Seizure?
Do you have Diabetes?
Are you pregnant, breastfeed, or nursing? (Female)
Is there anything you would like to add?

Consent to Botulinum Toxin A Treatment