Client Intake & Consent Form for Neurotoxin Services

Client Intake & Consent Form for Neurotoxin Services

Please fill out the following information and review the consent details to proceed with your treatment.
Patient Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Physician
Primary Care Physician Name

First NameLast Name
Primary Care Physician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Medical History and Screening
Please list all current medications (including supplements):
Please list all allergies (including medications, latex, food):
Are you currently pregnant or breastfeeding?
Do you have or have you ever had any of the following?

Other
Please describe any other relevant medical history:
Do you have any current symptoms or concerns?
Treatment Details
Which areas are you interested in treating with Botox?

Other
What are your primary goals for Botox treatment?
Have you discussed alternative treatments or options with your provider?
Informed Consent
Botox, Dysport, Xeomin, Jeuveau, and Daxxify are prescription medication used to relax muscles and reduce the appearance of wrinkles. Results are temporary and onset may take several days. Potential risks include bruising, swelling, headache, asymmetry, eyelid or brow droop, allergic reaction, infection, and unsatisfactory cosmetic result. No guarantees are made regarding the outcome. Aftercare instructions will be provided. You have the opportunity to ask questions before proceeding.
I consent to receive Botox treatment and have read and understood the information provided.
I consent to medical photography for documentation and/or educational purposes.
In the event of a medical emergency, I consent to receive appropriate medical care.
I acknowledge that I have received and reviewed the HIPAA Notice of Privacy Practices.
I acknowledge and accept the practice’s financial policy.
Aftercare and Questions
I acknowledge that I have received aftercare instructions and have had the opportunity to ask questions.
Signatures
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Client Intake & Consent Form for Neurotoxin Services

Patient Information

Emergency Contact

Primary Care Physician

Medical History and Screening

Treatment Details

Informed Consent

Aftercare and Questions

Signatures