I understand the information on this form is essential to determine my medical and botox needs.
I understand that if any changes occur in my medical history/health, I will immediately report it as soon as possible.
I acknowledge that all answers have been recorded truthfully and will not hold any staff member responsible for any errors or omissions that I have made in the completion of this form.
I am aware that when small amounts of purified botulinum toxin is injected into a muscle, it causes weakness/relaxation of that muscle. This effect generally appears in 2 – 10 days and the effects can last 3-4 months, but can be shorter or longer.
I understand that the length of response may change from patient to patient and from one treatment to the next.
I understand that I may not be able to “frown” while the injection is effective but that this will reverse after a period of months at which time retreatment is appropriate.
I am aware that the medicine practice is not an exact science.
I acknowledge that there are no guarantees that have been made or implied to me as to the results of the procedure.
I have read and understand the above medical history questionnaire.