Botulinum Toxin Consultation Form

Capture a patient's personal details and relevant background before administering a botulinum toxin treatment, including their informed consent.

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Client Name

Nombre

Apellido

Occupation

Birth Date

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Client Phone Number

Emergency Contact Name

Emergency Phone Number

Section

Do you suffer from any of the following diseases? (Please check all of the boxes that apply.)

Diabetes Heart Disease Autoimmune Disorder Bleeding/Clotting Disorder Skin Infection None of the above

Are you taking any of the medications or supplements listed below?

Blood Thinners Aspirin Antibiotics Vitamin E Supplements None of the above

Have you ever had an allergic/intolerances any reaction?

Yes No

If your answer is "Yes", please describe details:

Section

What is it about your face that troubles you the most?

What are your expectations?

What is it about your face that troubles you the most?

Additional Comments

Consent Confirmation

Name

Nombre

Apellido

Date

Signature

Sign here

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