Botulinum Toxin Consent Form
Name
First Name
Last Name
Age
Date of Birth
Gender
Please Select
Female
Male
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Take Photo
Patient History
*
Rows
YES/NO
Please list or Describe
Have you been treated for any skin issues before?
Yes
No
Is this your first time receiving botulinum treatment?
Yes
No
Have you ever been hospitalized? If so, please indicate why and when.
Yes
No
Have you had any previous surgeries? If so, please indicate the procedure name, reason, and date.
Yes
No
Do you have any known allergies to food, medication, or topicals?
Yes
No
Are you currently taking any medications? Please list all medications, including vitamins and supplements.
Yes
No
What is your current medical condition? Do you have any communicable diseases, cardiovascular problems, diabetes, asthma, etc.?
Yes
No
Are you pregnant or breastfeeding?
Yes
No
Is there anything else you would like for me to know?
Yes
No
Have you ever had cold sores/fever blisters, or been diagnosed with HSV?
Yes
No
Emergency Contact(s) Name and Phone Number
*
Type a question
I authorize AvLa Medspa to perform treatment with neuromodulators (Botox, Jeuveau, Xeomin, Dysport)
I understand the advantages and disadvantages of this procedure.
Common side effects: Headache, Eyelid drooping (ptosis), Upper respiratory infection (e.g., common cold), Injection site reactions (pain, swelling, redness, bruising, tenderness, soreness, bleeding, inflammation), Increased white blood cell count. Less common but potentially serious side effects: Spread of toxin effects: This can lead to botulism, a life-threatening emergency causing muscle weakness (away from the injection site), difficulty swallowing (dysphagia), speaking, or breathing. Allergic reactions: Hives, itching, rash, red itchy welts, wheezing, asthma symptoms, dizziness or feeling faint. Heart problems: Irregular heartbeat (arrhythmia) and heart attack. Eye problems: Dry eyes, reduced blinking, and corneal issues. Difficulty swallowing and breathing difficulties: These problems can be severe and potentially fatal, especially if pre-existing before injection. Hoarse voice and difficulty speaking. Loss of bladder control.
I allow taking my photos for documentation purposes.
I allow my photos to be used for portfolio or advertising.
I release AvLa Medspa for any responsibility in case of an accident, illness, or injury.
I understand the risk and complications if I do not follow instructions given to me after the procedure which involves post treatment and follow-ups.
I acknowledge that no assurance was offered about outcome.
I acknowledge that all information I provided on this form is true an accurate.
Signature of the Patient
*
Date
*
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Month
-
Day
Year
Date
Signature of the Physician
Date
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Month
-
Day
Year
Date
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