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Botox Patient History and Consent
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* Indicates required question
Name
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Phone number
*
Your answer
Email address
*
Your answer
Have you previously received botox?
*
Yes
No
If so, when was the last time you had botox?
MM
/
DD
/
YYYY
If applicable, please let us know the last target areas.
Your answer
Type of toxin received?
Your answer
Do you have any allergies?
*
Your answer
Do you have a history of anaphylactic shock?
*
Yes
No
Do you take any of the following medications or supplements?
*
Aspirins
Steroids
Anti-Inflammatories
Anticoagulants
Non-steroidals
Ginko Biloba
Vitamin A
Vitamin E
Garlic
Flax Oil
None
Required
Please list any other medications or supplements you take regularly
*
Your answer
Do you have or have you had any of the following medical conditions?
*
Eczema
Dermatitis
Cancer
Diabetes
Kidney Disorder
Epilepsy
Hormone Imbalance
Metal Plates
Claustrophobia
Anxiety
Depression
Nail Disorders
Allergies
Asthma
Heart Problems
HIV
Hepatitis
Stroke
Blood Disorders
Haemophilia
High Blood Pressure
Low Blood Pressure
Skin Disorders
Vision Problems
None
Required
Describe any other medical history below, as long as an explanation of any of the conditions you marked with "Yes."
Your answer
Are you pregnant, breastfeed, or nursing?
Yes
No
Clear selection
Do you have any special concern about any specific areas? If yes, please let us know.
Your answer
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