Sample patient questionnaires and consent forms. A downloadable word document version is linked from the bottom of each section.
Important Advisory: Taking aspirin, non-steroidal anti-inflammatory medication (NSAIDs) or anticoagulant medication before a Botox procedure is not recommended. Taking such products can increase bruising. If it is possible and prudent to stop these medications, you must do so at least one week before the Botox injections.
Some people are poor candidates for this procedure, including people with certain types of medical conditions. These include conditions that cause facial paralysis like Bell’s Palsy, Myasthenia Gravis and Guillain-Barre Syndrome. Women who are breastfeeding or pregnant should not use Botox.
The effects of a Botox procedure most often last from 3 to 5 months, but this can vary. Patients may experience relaxation or weakness in muscles adjacent to the targeted area. The most common side effect is eyelid droop, a condition called ptosis. This impact occurs in less than 3 percent of injections and is temporary. It usually resolves before the intended effects of the Botox wears off.
The primary side effects of Botox include injection pain and bruising, outcomes that are usually temporary and minor. In some cases, localized saline hypersensitivity can happen. Botox has been on the market for many years and there has never been a reported case of an allergic reaction.
When you sign this form, you consent and agree that you have read this document about Botox injection and understand that using aspirin, NSAIDs or any sort of blood thinner within the previous 3 days may result in an increased risk of bruising after the injections. You understand that this procedure, like all medical procedures, has side effects in some cases. You state that the staff of this facility have been provided a truthful and thorough medical history. You understand that additional injections may be required if the desired effect is not seen within 10 to 14 days of treatment and that this facility charges a retouch fee in such cases. You understand that the positive effects of Botox are temporary and last about 3 to 5 months and that repeat injections are necessary 3 or 4 times a year for continued effect.
You certify by signing this form that you have read the information in this document and completely understand it. You choose to proceed based entirely on the information provided in this informed consent document. You have been given all necessary opportunities for discussion and all your questions regarding Botox injections have been answered. You therefore and hereby consent to the care or treatment described herein. You assume related hazards, risks and costs or expenses associated with and arising from this treatment and release hereby all employees and consultants of this and other healthcare facilities and affiliates and agents from all liability from treatment except in cases where hazards or risk are the result of proven gross negligence.
This document is full disclose and supersedes any other written or verbal disclosures, advertising claims or marketing materials prepared by this facility or anyone else. It is further understood that this program is a specialty service and that this facility does not have overall responsibility for your general and comprehensive medical care.
If medical problems result from your Botox treatments, keep us informed of developments. If an urgent medical need arises, please contact your primary care physician, a hospital or an emergency clinic.
1. Avoid manipulating or rubbing in the area of the injection site for several hours. This can cause the Botox solution to migrate or move around, making it more likely to impact areas beyond the desired muscles.
2. Avoid exercising or excessively using the targeted muscle for at least 4 hours after the Botox injection procedure.
3. Avoid laying down or bending forward for at least 4 hours after the injection procedure. These actions can cause migration of the solution that can lead to complications and undesired outcomes or effects.
4. While you may see results in as little as 48 to 72 hours after injection, this is not typical. The majority of patients do not notice full impact from the treatment for 7 to 14 days. You should wait at least 30 days before deciding if you want additional treatment to avoid over-treating an area.
5. Although exceptionally rare, an allergic reaction to Botox is possible. If you notice skin redness of an extreme nature, excessive swelling or a developing rash, call the office immediately or arrange to be seen by a physician. The same is necessary if you experience puffy or very swollen eyes, a severe headache or other adverse reactions. Previous treatments can cause antibodies to develop that can lead to undesired reactions.
6. Feel free to contact this facility with questions, comments or concerns at any time following treatment. We want you to safe, happy and completely satisfied.
For this injection of Botox Cosmetic, Radiesse, Juvederm Ultra, Juvederm Ultra Plus and/or Juvederm XC and all future injections of these or similar products, I understand and consent that:
The facility staff will use the highest possible level of care and skill in doing my injections.
Everyone’s body reacts to injectables differently, and the effects may not be what I expect or the same as with previous injections of the same product or muscle.
No guarantees are made about the results of the injections or the longevity of results.
Refunds are not available under any circumstances.
Touchups are available, but there will be an additional charge per syringe or unit. Touchups of Botox are $13 per unit. Other product pricing varies.
Name:
Date:
Guardian’s Name if under age 18:
Address:
City: State: Zip:
Phone (Home):
Phone (Cell):
Age: Date of Birth:
Email Address:
I would like to receive emails about special offers:
Occupation:
Employer:
Preferred Pharmacy:
Pharmacy Phone:
How did you learn about our services?
Friend or Relative – Name:
Newspaper or Magazine – Name:
Doctor – Name:
Our Website
A Brochure Here
On-Hold Recording
Appointment Confirmations
May we leave a message for you on your machine or with the person who answers when calling to remind you of appointments?
Signature
Please be aware that there is a $20 missed appointment fee. If a deposit is required, deposit will be forfeited.
Initial
I was provided the required HIPPA privacy notice.
Initial
Name:
Date:
Date of Birth
Medical Details
(Please check all that apply.)
I have a history of anaplylaxis or severe allergies.
I have recently taken aspirin or ibuprofen. When?
I have an autoimmune disease like lupus, hepatitis or HIV.
I am currently on immunosuppressant therapy.
I bruise or cut easily.
I am currently breastfeeding or pregnant.
I have a history of keloid scarring.
I have recently visited a tanning booth.
I have a history of oral herpes outbreaks or fever blisters.
I have another condition not mentioned. What?
I am currently under care by a doctor. Why?
I am currently taking medication. What? (Please include over-the-counter medicines and herbal or dietary supplements taken regularly.)
I am interested in the following injectables:
Juvederm
Radiesse
Botox
I, (name) grant to this facility the right and permission to use images of me for the following purposes:
(check all that apply)
Use in my chart only
To be shown to other clients and potential clients to demonstrate possible results
Newspaper or online advertising
All purposes, including marketing purposes in all media
By signing this form, I give this facility and related companies or organizations the right and permission to use my name and images or photographs of me for the purposes above as well as educational purposes and release this facility from harm or detrimental consequences that may be experienced as a result of usage of these images in these ways. I release my images from confidentiality requirements as agreed.
I make these statements voluntarily and agree that all information contained herein is accurate. I understand that my image may be used in marketing and other activities without limit unless my selections above restrict usage.
