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Botulinum Toxin Treatment Consent Form

Secure a patient's informed consent before administering a botulinum toxin treatment, while reviewing their medical background and risk factors.

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Page 1

Patient Name

Nombre

Apellido

Date of Birth

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Are you currently taking any medical or dental treatment?

Yes No

Please list them

In the last one month, have you had any dermal treatments such as tattoos, dermal fillers, piercings or botulinum toxin?

Yes No

Please give details

Do you have any relevant past medical history

Yes No

Please list them

Have you recently received your COVID-19 vaccination?

Yes No

Are you pregnant or breast feeding?

Yes No

Do you have any allergies in your knowledge?

Yes No

Please list them

Did you get any aesthetic treatments before?

Yes No

Please give details

Please select if you suffer from any of the conditions listed below

Diabetes Autoimmune Disorder Skin Infection Bleeding Disorder None of the above

Please give details

Additional details you want to give

Page 2

Consent Statement

I agree to the following:

I consent to the botulinum toxin treatment described above

Name

Nombre

Apellido

Date

Sign

Sign here

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