Botulinum Toxin Consultation Form

1
Client Name
First Name
Last Name
2
Birth Date
Date
Month
Day
Year
3
Client Phone Number
Please enter a valid phone number.
4
Have you ever had an allergic/intolerances any reaction?
Yes
No
5
If your answer is "Yes", please describe details:
6
What is it about your face that troubles you the most?
7
What are your expectations?
8
Please check the box to indicate that you understand and agree with the following:
9
As Botulinum Toxin A is not an exact science, the appearance of the face may be uneven, with some muscles being more impacted by Botulinum Toxin A than others. Botulinum Toxin A injections in the same or surrounding muscles can usually rectify this uneven appearance. However, this uneven appearance might last for weeks or months in some circumstances.

In addition, the number of units injected provides a rough estimate of how much Botulinum Toxin A is needed to paralyze the muscles. I understand that no treatment can guarantee a positive outcome.
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Terms and Conditions* This field is required.
11
Name
First Name
Last Name
12
Date
Date
Month
Day
Year
13
Signature
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