BOTOX CUSTOMER FORM

GB Aestheta

219 St Leonards Rd , Norwich NR1 4JN
Botox Intake Form
CLIENT INFORMATION

First NameLast Name
DATE OF BIRTH
GENDER
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

CLIENT INTAKE BOTOX FORM
Are you allergic to any of the following substances?

Other
Are you currently taking any blood thinning drugs? (i.e., Aspirin and Warfarin)

Other
SKIN HISTORY SECTION
Are you currently taking or have recently taken any acne medications, i.e., Accutane, Epiduo?
Have you used Retin-A, any other vitamin-A derivatives, or AHAs in the last 3 months?
Have you had any chemical peel, microdermabrasion, micro needling, laser treatment, facial waxing or other cosmetic treatment in the last 3 months?
Have you had any surgeries, including plastic surgery?
Have you had injectable treatments (i.e. Botox, skin boosters/dermal fillers) in the last 12 months?

Release Form

photo & video
I, grant and authorize the right to take, edit, alter, use and publish photographs and/or videos of me for the purpose of promotional materials, including but not limited to:
- Print advertisements
- Online marketing (websites, social media, blogs)
- Educational materials (brochures, flyers, presentations)
I acknowledge that all photographs and/or videos taken are the property of [Your Business Name] and will be used solely for the purposes stated above.

I understand that by signing this release form, I grant [Your Business Name] permission to take, edit, alter, use and publish my photographs and/or videos without any further compensation or consideration. I waive any rights to compensation, financial or otherwise, for the use of these photographs and/or videos.

i release [Your Business Name], its representatives, and employees from any claims, damages or liabilities that may arise from the use of the photographs and/or videos, including any claims for compensation, defamation, or invasion of privacy.

By signing below, I acknowledge that I have read this release form, understand its content, and voluntarily agree to its terms.
CLIENTS DETAILS

First NameLast Name
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Policy Form

cancellation
At GB Aestheta , we strive to provide an exceptional standard of care. In order to achieve this, we kindly request your cooperation in adhering to our cancellation policy.
We understand that life can be unpredictable and unexpected circumstances may arise. However, we kindly ask that you provide us with at least 24 hours' notice if you need to cancel or reschedule your appointment. Your deposit will be refunded or applied to a new appointment.
Cancellations made within 24 hours of the scheduled appointment time are subject to a 50£ cancellation fee.
While we understand that unforeseen circumstances can occur, a missed appointment where no notice is given not only affects our ability to serve other clients but also results in lost time and resources. The full cost of the service is charged for these appointments.
We value your time as well as the time of our other clients. If you arrive more than 15 minutes late for your scheduled appointment, we may need to reschedule your session or shorten the treatment duration. The full price of the originally scheduled appointment will still apply.
We truly appreciate your understanding and cooperation in honoring our cancellation policy to ensure that each client receives the attention and quality service they deserve.
CLIENTS DETAIL

First NameLast Name
DATE

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

Consent form

botox
I consent to receiving Botox injections, understanding that this involves the injection of a neurotoxin derived from Clostridium Botulinum bacteria. The procedure aims to reduce wrinkles by temporarily inhibiting muscle contractions in specific areas of my face. I acknowledge that there are risks with this procedure, which include, but are not limited to:
- Allergic reactions can occur, with itching, rash, or hives, and more rarely, anaphylaxis.
- Asymmetry is possible, with temporary drooping of facial features like eyebrows, cheeks, and mouth.
- Dry eyes and double or blurred vision.
- Temporary symptoms may include headache, swelling, bruising, bleeding, discomfort, twitching, puffiness/oedema, numbness, alterations in sensation or infection at the injections site.
- Less commonly observed but serious effects may include the rare spread of medicine to unintended body areas, leading to symptoms such as muscle weakness, vision problems, difficulty speaking or swallowing, breathing issues, allergic reactions, or loss of bladder control. Seek immediate medical attention if any of these symptoms occur.
I understand that other unforeseen risks, other than those listed, may arise, and I agree that I will seek medical attention at my own expense if necessary. I understand that it is my responsibility to disclose any health condition or medication that might affect the treatment. I acknowledge Botulinum Toxin works best for dynamic facial lines caused by muscle activity. Lines at rest may not improve; individual results vary, and multiple treatments may be needed for desired results.

By signing below, I confirm that I have been fully informed of the potential risks, benefits, and complications and I voluntarily agree to taking this medication. I have had the opportunity to ask questions, and all my concerns have been addressed to my satisfaction. I release GB Aestheta from any liability or claims arising from the treatment.
CLIENTS DETAIL

First NameLast Name
CLIENTS SIGNATURE

Care advice

botox
Your body will recover more quickly and have optimal results when you maintain a regimen to support your health and well-being.

Pre-treatment advice:

Avoid alcohol and excessive caffeine for 48 hours. These substances can dehydrate the body and increase bruising.
Minimize direct sun exposure and avoid tanning beds for a week prior to your treatment.
Drink 2L of water a day for 1 week before treatment.
If you are using blood thinners, speak to your medical provider about whether they recommend pausing them prior to treatment.
On the day of your treatment, keep the skin clean and free of any lotions or perfumes, and avoid vigorous exercise.

Post-treatment advice:

You may experience redness, swelling, and mild discomfort which subsides within a few days. Take paracetomol/Tylenol for pain, but avoid NSAIDs, which can increase bruising.
Avoid acids, retinols and Vitamin C for 72 hours.
Avoid touching, rubbing, or massaging the injected area for at least 24-48 hours.
Apply cold compresses to the treated area for 10-15 minutes at a time to help reduce swelling, bruising and discomfort.
If post-injection bruising occurs, Arnica gel can be used.
Refrain from hot baths, saunas, and activities that may cause excessive sweating for at least 48 hours post-treatment.
Avoid sun/tanning beds for 2 weeks and use SPF in the area.
Stay hydrated and drink plenty of water.
Attend follow-up appointments for optimal results.
Should be Empty:

GB Aestheta

Botox Intake Form

CLIENT INTAKE BOTOX FORM

SKIN HISTORY SECTION

Release Form

Policy Form

Consent form

Care advice