Botulinum Toxin Consultation Form

Botulinum Toxin Consultation Form
Personal Information
Client Name
First NameLast Name
Occupation
Birth Date
MonthDayYear
Date
Address
Street Address
Street Address Line 2
CityState
Zip CodeCountry
Client Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name
Emergency Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
- Do you suffer from any of the following diseases? (Please check all of the boxes that apply.)
  Skin diseaseHIV/AIDSHigh Blood PressureCancerDiabetesLambert-Eaton SyndromeThyroid ImbalanceParkinson’sOther
- Are you taking any of the medications or supplements listed below?
  Omega 3 Fatty AcidsAnti-depression medicationFlax seed oilVitamin EAspirinOther
- Have you ever had an allergic/intolerances any reaction?
  YesNo
- If your answer is "Yes", please describe details:
- 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.
- Name
  First NameLast Name
- Date
  MonthDayYear
  Date
- Signature
  Clear
- Should be Empty:

Botulinum Toxin Consultation Form

Personal Information