Free Botox & Filler Consent Form Template

Are you struggling to ensure that your patients are fully informed before their cosmetic procedures? This Botox & Filler Consent Form Template helps medical offices collect vital information from clients seeking cosmetic enhancements, ensuring transparency and understanding. With it, you can simplify the documentation process, enhance patient trust, and stay compliant with medical regulations. Additionally, it's designed with clear, WCAG-aligned labels for improved accessibility. Discover how this template can streamline your practice and improve patient satisfaction.

When to use this form

Use this form before any neuromodulator (Botox) or dermal filler appointment. It suits med spas, dermatology clinics, plastic surgery offices, and RN injectors, especially with new clients, treatment changes, or dose adjustments. Capture health history, allergies (including to lidocaine or botulinum toxin), medications, pregnancy status, and past outcomes. You also set expectations for results, touch-ups, risks, downtime, and aftercare, and record photo consent. For multi-service studios, align policies by using the Waxing waiver form for body services. This keeps workflows consistent and reduces gaps across your client journey.

Must Ask Botox & Filler Consent Questions

Do you have any allergies, medical conditions, or prior reactions to botulinum toxin, dermal fillers, or anesthetics (e.g., lidocaine)?
This flags contraindications so you can adjust products, doses, or defer treatment. Call out any brand-specific issues, including Allergan products, to reduce risk and document informed consent.
Are you pregnant, breastfeeding, or planning to conceive in the next 3 months?
These situations are standard reasons to postpone injectables. A clear record supports safe decisions and protects your practice.
What prescription medications, supplements, or recent dental/medical procedures should we know about?
Blood thinners, antibiotics, and recent dental work can increase bruising or infection risk. Knowing the timing and dosage helps you schedule safely and tailor aftercare.
What areas do you want treated, and what results are you expecting?
This aligns goals with anatomy and product choice, and sets realistic limits. If skin quality is the primary concern, you can suggest a complementary intake like the Facial treatment consultation form.
Do you consent to treatment today, understand the risks and benefits, and agree to clinical photographs for your medical record?
Combining treatment and photo consent keeps documentation clear for dosing, mapping, and follow-ups. It supports continuity of care and reduces disputes.

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Question		Response
Full name		John Smith
Date of birth		2025-10-15T00:00:00.000Z
I am 18 years of age or older		True
Gender		Prefer not to say
If you prefer to self-describe your gender, please specify		This is a test
Email address		[email protected]
Mobile phone number		555 555 5555
Preferred contact method		No preference
Do you currently have or have you ever had any of the following conditions?		Seizure disorder
Are you pregnant, breastfeeding, or trying to conceive?		No
Do you have an active cold sore or frequent cold sore outbreaks?		No
Have you had any recent dental work or do you have dental work planned in the next 2 weeks?		No
Have you received a COVID-19 vaccination within the past 2 weeks or do you plan to in the next 2 weeks?		No
Please indicate any known allergies		Albumin
List any other allergies (foods, drugs, environmental)		This is a test
List all current medications and supplements (include dose if known)		This is a test
Are you currently taking any of the following?		Apixaban (Eliquis)
If yes or not sure, please describe the reaction and when it occurred		This is a test
Have you ever had an adverse reaction to injections, vaccines, anesthetics, or fillers?		Yes
Have you had any cosmetic injections in the last 12 months?		Biostimulators (e.g., Sculptra, Radiesse)
Date of your most recent cosmetic injection (if applicable)		2025-10-15T00:00:00.000Z
Have you experienced any complications from previous cosmetic treatments?		Allergic reaction
If other areas, please specify		This is a test
Areas of concern you would like treated today		Crow's feet
I authorize the clinician to perform Botox and/or dermal filler injections on me.		1
I understand these are elective cosmetic treatments and that results are temporary and can vary between individuals.		1
I have disclosed my complete and accurate medical history, allergies, and current medications/supplements.		2
I understand potential risks, including bruising, swelling, pain, infection, asymmetry, nodules, granulomas, vascular occlusion, tissue loss, vision changes/blindness, drooping, headache, and flu-like symptoms.		3
I understand there is no guarantee of specific results and that additional treatments or touch-ups may be required.		3
I understand that off-label use of products may be performed when clinically appropriate and discussed with me.		4
I will follow all pre- and post-care instructions and seek immediate care for severe pain, blanching, vision changes, or other concerning symptoms.		4
I acknowledge that treatment should be avoided during pregnancy or breastfeeding.		2
I consent to the use of hyaluronidase to dissolve filler if medically indicated.		No
I consent to the use of topical or local anesthetics if needed.		No
Do you consent to proceed with the recommended treatment today?		Yes
I consent to clinical photographs for documentation in my medical record.		No
I consent to the use of de-identified photos for education and marketing (e.g., website, social media).		Yes
Preferred follow-up contact method(s) for check-ins after treatment		Phone call
Emergency contact full name		This is a test
Emergency contact phone number		555 555 5555
Emergency contact relationship to you		This is a test
Primary care physician name		This is a test
Primary care physician phone number		555 555 5555
Patient signature (type full legal name)		This is a test
Signature date		2025-10-15T00:00:00.000Z
If signing as a parent/guardian for a minor, provide your name and relationship		This is a test
I have had the opportunity to ask questions and all were answered to my satisfaction.		3

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Botox & Filler Consent Form Template

Streamline patient onboarding with an effective consent form

When to use this form

Must Ask Botox & Filler Consent Questions

More Forms

Unlock hundreds more featuresSave your Form to the DashboardView and Export ResultsUse AI to Create Forms and Analyse Results

Botox & Filler Consent Form Template

Streamline patient onboarding with an effective consent form

When to use this form

Must Ask Botox & Filler Consent Questions

More Forms

Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results