Botulinum Toxin Consultation Form
Personal Information
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Client Phone Number
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Emergency Contact Name
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Medical History
Do you suffer from any of the following diseases? (Please check all of the boxes that apply.)
Skin disease
HIV/AIDS
High Blood Pressure
Cancer
Diabetes
Lambert-Eaton Syndrome
Thyroid Imbalance
Parkinson’s
Other
Are you taking any of the medications or supplements listed below?
Omega 3 Fatty Acids
Anti-depression medication
Flax seed oil
Vitamin E
Aspirin
Other
Have you ever had an allergic/intolerances any reaction?
Yes
No
If your answer is "Yes", please describe details:
Facial History
What is it about your face that troubles you the most?
What are your expectations?
What is it about your face that troubles you the most?
Please check the box to indicate that you understand and agree with the following:
As Botulinum Toxin A is not an exact science, the appearance of the face may be uneven, with some muscles being more impacted by Botulinum Toxin A than others. Botulinum Toxin A injections in the same or surrounding muscles can usually rectify this uneven appearance. However, this uneven appearance might last for weeks or months in some circumstances.
In addition, the number of units injected provides a rough estimate of how much Botulinum Toxin A is needed to paralyze the muscles. I understand that no treatment can guarantee a positive outcome.
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