Botulinum Toxin Consent Form
Please complete this form to provide your informed consent for the administration of botulinum toxin (Botox) treatment.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Have you previously received botulinum toxin (Botox) treatments?
*
Yes
No
Please list any allergies you have (including to medications or botulinum toxin). If none, write "None".
*
Are you currently taking any medications or supplements? Please list them. If none, write "None".
*
Do you have any of the following conditions? (Select all that apply)
*
Neuromuscular disorders (e.g., myasthenia gravis, ALS)
Pregnant or breastfeeding
Active skin infection in the treatment area
None of the above
Other
Please indicate the area(s) you wish to have treated with botulinum toxin (Botox).
*
Forehead
Glabella (frown lines)
Crow's feet (around eyes)
Other area(s)
Signature (Please sign below to confirm your consent)
*
Submit Consent
Submit Consent
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