Botox Consent Form
Patient Information
Patient Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
Weight (kg)
Height (cm)
Email Address
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical Health Data
Blood Type
A
B
AB
O
Please answer the following:
Rows
Yes/No
Description/Remarks
Have you been treated for any dermal issues before?
Yes
No
Is this your first time receiving botox treatment/
Yes
No
Have you ever been hospitalized? If yes, please indicate why and when.
Yes
No
Did you undergo any previous surgery? If yes, please indicate the procedure name, reason, and the date.
Yes
No
Do you have any known allergies? If yes, then please specify in the Description field.
Yes
No
Are you currently taking medications? If yes, then please list the medications and the reasons why are you taking them.
Yes
No
What is your current medical condition? Do you have any communicable disease, cardiovascular problems, diabetes, asthma, etc.?
Yes
No
Are you pregnant, breastfeed, or nursing? (Female)
Yes
No
Is there anything you would like to add?
Yes
No
Emergency Contact Details
Contact Name
First Name
Last Name
Primary Phone Number
-
Area Code
Phone Number
Secondary Phone Number
-
Area Code
Phone Number
Acknowledgment, Authorization and Release
I authorized this clinic to perform the procedure stated above (Botox Cosmetic Treatment).
I understand the advantages and disadvantages of this procedure. The physician explained the process thoroughly to me.
I allow this clinic to administer anesthesia and understands the effects of the medications given to me.
I understand the side effects that I may experience after the procedure. Side effects: Nausea and vomiting, headache, body weakness, paralysis of the affected area, facial alignment issue, a bruising, respiratory infection.
I allow taking my photos or the procedure images that can be used for the clinic portfolio or advertising.
I release this clinic for any responsibility in case of an accident, illness, or injury.
I understand the risk and complications if I do not follow the instructions given to me after the procedure which involves post-treatment and follow-ups.
I acknowledge that no assurance was offered about the outcome.
I acknowledge that all information I provided int his form is true and accurate.
Signature of the Patient
Date Signed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of the Physician
Date Signed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: