Full Name

Date of birth

Multi Dropdown 1ziu

Single Line 96er1

Email *

Phone *

Number 6wbq

Single Line 96qcc

Single Line 97cam

I acknowledge that: *

Temporary redness, swelling, or bruising at the injection site

I understand the potential risks, side effects, and healing process of dermal fillers.

I have been informed that results vary from person to person and that touch-ups may be required.

I understand that swelling and bruising are common and that final results may take up to two weeks.

I will follow all pre- and post-treatment care instructions provided to me.

I consent to the dermal filler treatment and understand the risks involved.

Medical History

Please check any conditions that apply to you:

Neuromuscular disorders (e.g., myasthenia gravis)

Bleeding disorders or clotting issues

Allergies to botulinum toxin products, eggs, or any ingredients in Botox

History of facial surgery or previous cosmetic procedures in the treatment area

Active infection, cold sores, or skin infections near the injection site

Eye disorders or conditions affecting the eyelids

Other...

Women only:

Are you pregnant, planning to conceive, or breastfeeding?

Yes

No

Medications & Allergies

Are you currently taking any medications? (e.g., blood thinners, muscle relaxants, supplements)

Yes

No

If yes, please list:

Have you had previous Botox treatments?

Yes

No

If yes, when?

Do you have any known allergies to medications or skincare products?

Yes

No

If yes, list:

Treatment Information & Risks

Botox is an FDA-approved injectable treatment used to reduce the appearance of dynamic wrinkles by temporarily relaxing targeted facial muscles. The treatment involves a series of small injections into the designated muscles.

Possible side effects and risks include but are not limited to: *

Temporary redness, swelling, or bruising at the injection site

Mild headache or flu-like symptoms

Temporary drooping of the eyelids or eyebrows (ptosis)

Asymmetry or uneven facial expressions

Rare allergic reactions or localized pain

In very rare cases, spread of toxin effects leading to muscle weakness

Contraindications:

Botox is NOT recommended if you:

• Have an active infection near the treatment area

• Have known allergies to any ingredients in the Botox formulation

• Are pregnant or breastfeeding (unless advised otherwise by your physician)

• Have any neuromuscular disorders that might affect the outcome

Consent & Acknowledgment

I acknowledge that: *

I have provided complete and accurate information regarding my medical history, current medications, and any known allergies.

I understand the Botox procedure, its potential benefits, risks, and side effects.

I have been informed that individual results may vary and that multiple sessions or adjustments might be necessary to achieve the desired outcome.

I agree to follow all pre- and post-treatment care instructions provided by my practitioner.

I understand that while complications are rare, they can occur, and I consent to the Botox treatment under these terms.

By signing below, I confirm that I have read and understood the information provided and consent to proceed with the Botox treatment.

Patient Name (Print): *

Patient Signature: *

Clear

Date: *

Practitioner Name (Print): *

Practitioner Signature: *

Clear

Date: *

I agree to terms & conditions provided by the company.

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