Botox Treatment Informed Consent Form

Botox Treatment Informed Consent Form
Introduction:

This consent form is designed to provide you with the information you need to make an informed decision about undergoing Botox injections for cosmetic purposes. Please read this form carefully and ask any questions you might have.
Patient Information
Patient Name

First NameLast Name
Date

MonthDayYear
Date
Age
Date of Birth

MonthDayYear
Date
Gender
Weight (kg)
Height (cm)
Email Address
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical Health Data
Blood Type

Please answer the following:

	Yes/No	Description/Remarks
Have you been treated for any dermal issues before?
Is this your first time receiving botox treatment/
Have you ever been hospitalized? If yes, please indicate why and when.
Did you undergo any previous surgery? If yes, please indicate the procedure name, reason, and the date.
Do you have any known allergies? If yes, then please specify in the Description field.
Are you currently taking medications? If yes, then please list the medications and the reasons why are you taking them.
What is your current medical condition? Do you have any communicable disease, cardiovascular problems, diabetes, asthma, etc.?
Are you pregnant, breastfeed, or nursing? (Female)
Is there anything you would like to add?

Procedure Description:

Botox injections involve the use of Botulinum Toxin, which temporarily relaxes the muscles by blocking nerve impulses. The result is a reduction in the appearance of wrinkles, typically in areas such as the forehead, around the eyes, and between the eyebrows.
Procedure Details:
Treatment Area/s : _____________________________
Product Used : _____________________________
Potential Benefits:
- Reduction in the appearance of facial wrinkles

- Enhanced facial symmetry

- Temporary improvement in the overall appearance of the face.
Risks and Complications:
- Temporary bruising, swelling, or redness at the injection site

- Allergic reactions, such as itching or rash

- Infection at the injection site

- Headache or flu-like symptoms

- Temporary eyelid droop

- Facial pain, redness or swelling

- Muscle weakness near treated areas

- Nausea

- Unintended paralysis of nearby muscles

- Unsatisfactory results
Aftercare Instructions:
- Avoid touching or massaging the treated areas for at least 24 hours

- Stay upright and avoid bending over for several hours post-treatment

- Refrain from engaging in heavy physical excercises for 24 hours

- Follow specific aftercare instructions provided by your healthcare provider
Financial Responsibilities:
Please note that Botox treatments are typically not covered by insurance when performed for cosmetic reasons. You are responsible for the full payment of the procedure.
Emergency Contact Details
Contact Name

First NameLast Name
Primary Phone Number

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
Acknowledgment, Authorization and Release
I authorized this clinic to perform the procedure stated above (Botox Cosmetic Treatment).I understand the advantages and disadvantages of this procedure. The physician explained the process thoroughly to me.I allow this clinic to administer anesthesia and understands the effects of the medications given to me.I understand the side effects that I may experience after the procedure. Side effects: Nausea and vomiting, headache, body weakness, paralysis of the affected area, facial alignment issue, a bruising, respiratory infection.I allow taking my photos or the procedure images that can be used for the clinic portfolio or advertising.I release this clinic for any responsibility in case of an accident, illness, or injury.I understand the risk and complications if I do not follow the instructions given to me after the procedure which involves post-treatment and follow-ups.I acknowledge that no assurance was offered about the outcome.I acknowledge that all information I provided int his form is true and accurate.
Consent:

I have read and understood the information provided above regarding Botox injections. I have had the opportunity to ask questons, and all my questions have been answered satisfactorily. I undersand the benefits and risks associated with Botox injections and consent to proceed with the treatment. I hereby release the practitioner and the clinic from any liability associated with this procedure.
Signature of the Patient

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Date Signed

MonthDayYear
Date
Signature of Provider

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Should be Empty:

Botox Treatment Informed Consent Form

Introduction:

Patient Information

Medical Health Data

Procedure Description:

Procedure Details:

Potential Benefits:

Risks and Complications:

Aftercare Instructions:

Financial Responsibilities:

Emergency Contact Details

Acknowledgment, Authorization and Release

Consent: