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Botox Intake Form

Botox, Xeomin, & Dysport Consent & Liability Waiver

Birthday
Month
Day
Year
Date of Procedure
Month
Day
Year
Have you ever received Botox, Xeomin, Dysport, or any other botulinum toxin treatment before?
Yes
No
Have you ever had an adverse reaction to botulinum toxin
Yes
No
Do you have any of the following conditions? (Check all that apply)
Do you have any known allergies?
Yes
No
Do you currently have any of the following in the treatment area? (check all that apply)
Have you had any facial procedures in the last 4 weeks? (Fillers, laser, micro needling, facials, surgery, etc)
Yes
No
Are you taking any blood thinners or medications that may increase bruising? (e.g., aspirin, warfarin, Eliquis, Plavix)
Yes
No
Have you consumed alcohol in the past 24 hours?
Yes
No

PURPOSE OF TREATMENT

I understand that Botulinum Toxin Type A products including Botox®, Xeomin®, and Dysport® are FDA‑approved neuromodulators used to temporarily reduce the appearance of facial wrinkles and fine lines by relaxing targeted muscles. Results vary by individual and are temporary, typically lasting 3–4 months.

PROCEDURE

I understand that the procedure involves injecting small amounts of botulinum toxin into specific facial muscles using a fine needle. The number of injections and units used will be determined by the licensed medical provider based on my anatomy, goals, and clinical judgment.

POTENTIAL RISKS & SIDE EFFECTS

I acknowledge that, although uncommon, the following risks and side effects may occur:

  • Redness, swelling, bruising, tenderness, or pain at injection sites

  • Headache or flu‑like symptoms

  • Temporary muscle weakness or asymmetry

  • Drooping of the eyelid or brow (ptosis)

  • Dry eyes or excessive tearing

  • Nausea

  • Infection

  • Allergic reaction (rare)

  • Unsatisfactory results or need for additional treatments

I understand that serious complications are rare but may include difficulty swallowing, speaking, or breathing, and I should seek immediate medical attention if these occur.

CONTRAINDICATIONS

I confirm that I have disclosed my full medical history and understand that I may not be a candidate for treatment if I:

  • Am pregnant, trying to become pregnant, or breastfeeding

  • Have a neuromuscular disorder (e.g., ALS, Myasthenia Gravis)

  • Have a known allergy to botulinum toxin or any of its components

  • Have an active infection at the injection site

RESULTS & EXPECTATIONS

I understand that:

  • Results are not immediate and may take 3–14 days to appear

  • Full results may take up to 2 weeks

  • Results are not guaranteed

  • Touch‑ups may be recommended at an additional cost

POST‑TREATMENT CARE

I agree to follow all post‑treatment instructions provided, including avoiding rubbing or massaging treated areas, strenuous exercise, alcohol consumption, and lying flat for a specified period after treatment.

LIABILITY WAIVER & RELEASE

I acknowledge that I have been fully informed of the nature, purpose, benefits, risks, and possible complications of botulinum toxin injections. I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction.

I voluntarily consent to treatment and release, waive, and hold harmless the medical provider, practice, employees, contractors, and affiliates from any liability, claims, or damages arising from or related to this treatment, except in cases of gross negligence or willful misconduct.

FINANCIAL RESPONSIBILITY

I understand that I am financially responsible for this procedure and that no refunds are provided for services rendered.

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