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Botox & Filler Consent Form

A clinical intake form that collects a patient's health history before administering botox or dermal filler treatments.

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Page 1

Name*

First Name

Last Name

Date of Birth*

Address

Street Address

City

State / Province

ZIP / Postal Code

Phone Number

Please select any conditions that apply to you:

Pregnancy Diabetes Blood clotting disorder Allergies Skin infection Autoimmune disease None

I have these allergies:

I take these pills/medications:

If female, are you or do you think you may be pregant?

If you smoke, how many cigarettes do you smoke per day?

If you smoke, how many years have you smoked for?

How many units of alcohol do you drink per week?

How many times per day do you brush your teeth?

Do you brush your teeth with fluoride toothpaste?*

How often per week do you floss your teeth?

Your Doctor Name

First Name

Last Name

address of your doctor

Street Address

City

State / Province

ZIP / Postal Code

Please select any conditions that apply to you (contraindications for botox):

Pregnancy or breastfeeding Neuromuscular disease Allergy to botulinum toxin Infection at injection site None

Please select any conditions that apply to you (contraindications for fillers):

Pregnancy or breastfeeding Allergy to hyaluronic acid Active skin infection Autoimmune disorder None

Additional Notes

Patient Initials

Signature*

Sign here

Page 2

I am undertaking this procedure to improve my physical wellbeing and should this procedure be rescheduled, delayed or cancelled it will have negative impact on my general health.

I agree I disagree

Additional health comments

Have you tested positive for COVID-19 in the last 7 days?*

Yes No

Are you waiting for a COVID-19 test or the results?*

Yes No

Do you live with someone who has either tested positive for COVID-19 or had symptoms of COVID-19 in the last 14 days?*

Yes No

Do you have any of the following symptoms:

Fever Cough Loss of taste or smell Sore throat Shortness of breath None

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