PHONE*
EMAIL*
EMERGENCY CONTACT NAME
PHONE NUMBER
DERMAL FILLER & NEUROTOXIN consultation form
Are you currently taking blood thinning medication?
If yes, please explain:
Are you currently pregnant or trying to get pregnant?
Do you have any implants ?
Have you had any Botox/Dermal Filler treatments recently?
If yes, please state when & explain:
Have you had any adverse reactions to any previous treatment
Have you exfoliated or applied any products to your face in the last 24hours? please state which products:
Have you had any allergic reactions to any of the following?
AsprinLidocaine(Anesthetic)EggsNeurotoxinCollagenHydrocortisone
COSMETIC TREATMENT OF SURGERY HISTORY
Dermal FillersNeurotoxinsOther
By signing below, you agree to the following: I have completed this form truthfully and to the best of my knowledge. I agree to waive all liabilities toward my medical members and the employer for any injury or damages incurred due to any falsification of my medical history
Client Name ( Printed )
Date
BOTOX & NEUROTOXIN CLIENT CONSENT FORM
CLIENT FULL NAME:
Please initial each statement:
During the course of the treatment, despite all precautionary measures taken by the technician, it's important to recognize that there is a possibility of injury. I will not hold the technician responsible for any issues that may arise as a result of undergoing the procedure.I understand that there are inherent risks associated with botulinum toxin/Botox. If I experience any form of adverse reaction, I will promptly seek medical attention and inform my technician.It is my responsibility to communicate any concerns I may have to the technician before the procedure.I understand and agree to follow the aftercare instructions provided by my technician. I am aware that not adhering to the aftercare instructions may impact the achievement of the desired results.I acknowledge that the product will be injected into the muscles of my face as part of the botulinum/Botox process. The technician performing the procedure will not be held liable for any damages to my skin or me for any reason, especially if I fail to follow aftercare instructions.I have disclosed all pertinent medical history, and I commit to informing my technician of any changes that may occur in the future.
By signing below, I hereby acknowledge that I have read and understand all the information in this informed consent agreement. I understand that this agreement is legal and binding and will remain in effect for this procedure and all future follow-ups conducted by [YOUR COMPANY NAME HERE], and any of their associates. I fully understand the risks and side effects associated with the treatment. I freely assume these risks and release [YOUR COMPANY NAME HERE], and any of their associates of all liability.
