Botox and Filler Consent

1
Patient Information* This field is required.
First Name
Last Name
Date of BIrth
2
Request for Treatment* This field is required.Please scroll to the bottom to review before checking the box.
3
Nature and Purpose of the Procedure* This field is required.Please scroll to the bottom to review before checking the box.
4
Disclaimer of Guarantees and Explanation of Material Risks* This field is required.Please scroll to the bottom to review before checking the box.
5
Medical History* This field is required.Please scroll to the bottom to review before checking the box.
6
Follow Up Treatment* This field is required.Please scroll to the bottom to review before checking the box.
7
Acknowledgement of Informed Consent* This field is required.Please scroll to the bottom to review before checking the box.
8
Have you taken any blood thinners or NSAIDS in the past 24 hours?
YESNO
9
Have you had a BOTOX® or JUVEDERM® COLLECTION OF FILLERS injected before?
YESNO
10
BOTOX® and JUVEDERM® History
Please Select
Please Select
BOTOX®
JUVEDERM®
BOTOX® and JUVEDERM®
What treatment(s) have you had?
When was your last treatment?
Any reaction to previous treatments?
11
Patient Signature* This field is required.By signing you are agreeing that you have read and accept the Botox and Filler Informed Consent. Please use your finger or mouse to sign.
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