BOTOX MEDICAL HISTORY

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Name(Required)

First Last

Email(Required)

D.O.B(Required)

MM slash DD slash YYYY

Phone(Required)

Street Address(Required)

City(Required)

State(Required)

Zipcode(Required)

Please list all medications you are currently taking:

Allergies:

Are you on antibiotics at this time?(Required)

Yes

WOMEN: Are you pregnant, trying to get pregnant, or lactating (nursing)?

Check any of the following illnesses you have or have ever had in the past:

Myasthenia Gravis

Hepatitis

Eye Disease

Autoimmune Disease

Vision Problems

Numbness

Muscle Weakness

Multiple Sclerosis

Amyotrophic Lateral Sclerosis (ALS)

Parkinson’s Disease

Neurological Disorder

Lambert-Eaton Syndrome

List any other medical conditions not listed above

Previous Hospitalizations/Operations:

Have you had plastic surgery or other surgery to your face/neck areas?

Yes

If so, when?

Have you had BOTOX injections before?(Required)

Yes

Last treatment date?(Required)

MM slash DD slash YYYY

What areas?(Required)

Were you happy with your previous BOTOX treatment?(Required)

Yes

Explain:

Have you ever had an eyelid/eyebrow droop after BOTOX?(Required)

Yes

Do you show a lot of upper eyelid when your eyes are open?(Required)

Yes

Do your eyelids feel extra heavy when you don’t get enough sleep?(Required)

Yes

Do your eyelids droop without sleep?(Required)

Yes

Areas of special concern?

* I understand the information on this form is essential to determine my medical and cosmetic needs and the provision of treatment. I understand that if any changes occur in my medical history/health I will report it to the office as soon as possible. I have read and understand all the above medical history questionnaire.I acknowledge that all answers have been recorded truthfully and will not hold any staff member responsible for any errors or omissions that I have made in the completion of this form.(Required)

Patient Signature

CONSENT TO BOTOX BOTULINUM TOXIN “A” TREATMENT

Botox is a neurotoxin produced by the bacterium Clostridium A. Botox can relax the muscles on areas of the face and neck which cause wrinkles associated with facial expressions. Treatment with Botox can cause your facial expression lines or wrinkles to essentially disappear. Areas most frequently treated are: glabellar area of frown lines, located in between the eyes; crow’s feet; and forehead wrinkles. Botox is diluted to a very controlled solution and when injected into the muscles with a very thin needle, it’s almost painless. Clients might feel a slight burning sensation while the solution is being injected. The procedure takes about 15-20 minutes and the results last 3-6 months. With repeated treatments, the results may tend to last longer.

RISKS & COMPLICATIONS:

It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure and in this specific instance such risks include but are not limited to: Post treatment discomfort- i.e. swelling, redness, bruising; Double vision; Rarely weakened tear duct; Post treatment bacterial, and/or fungal infection requiring further treatment; Allergic reaction; Minor temporary droop of eyelid(s) in approximately 2% of injections, that usually last 2-3 weeks; Transient headache; Flu-like symptoms may occur

PHOTOGRAPHS:

I authorize the taking of clinical photographs and their use for scientific purposes both in publications and presentations. I understand my identity will be protected.

PREGNANCY, ALLERGIES, & NEUROLOGICAL DISEASE:

I am not aware that I am pregnant, I am not trying to get pregnant, and I am not lactating (nursing), have any significant neurologic disease including but not limited to Myasthenia Gravis, Multiple Sclerosis, Lambert-Eaton Syndrome, Amyotrophic Lateral Sclerosis (ALS), Parkinsons, or that I have any allergies to the toxin ingredients, or to human albumin.

PAYMENT:

I understand that this is an “elective” cosmetic procedure and that payment is my responsibility

RESULTS:

I am aware that when small amounts of purified botulinum (BOTOX) are injected into a muscle, it causes weakness or paralysis of that muscle. This appears in 2-10 days and usually lasts 3-6 months but can be shorter or longer. In a very small amount of individuals, the injections do not work as satisfactorily, or for as long as usual. There are some individuals that do not respond at all. I understand that I will not be able to “frown” while the injection is effective but that this will reverse after a period of months at which time re-treatment is appropriate. I understand that I must stay in the upright posture and that I must not manipulate the area(s) of the injections for the 2 hours post-injection period. I understand that this is an elective procedure and I hereby voluntarily consent to treatment with BOTOX injection for the condition known as: Facial Dynamic Wrinkles. The procedure has been fully explained to me. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure and I understand that no guarantees are implied as to the outcome of the procedure. I also certify that if I have any changes in my medical history I will notify the office immediately.

Patient Name (Print)(Required)

Patient Signature(Required)

Witness Name (Print)(Required)

Witness Signature(Required)

This form is to serve as consent to add any communication, including text messages, emails, and photos, to your patient chart. We will also notate any phone conversations regarding treatment. This will help us to give the best treatment possible.

Thank you for your cooperation.

Patient Signature(Required)

Botox Medical History Form