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Botox Consent Form Template

Streamline Your Botox Procedure with a Clear Consent

Navigating patient consent can be challenging, especially when it comes to cosmetic procedures like Botox. This Botox consent form template is designed specifically for practitioners and clinics, ensuring your patients are fully informed and protected. By using this template, you can clearly outline treatment risks, document patient understanding, and maintain organized records, all while ensuring compliance with WCAG-aligned standards. It's the straightforward way to enhance patient communication and streamline your administrative processes. Try the live template to see how easy it can be.

Use this Template (FREE) Live Preview
Full legal name
Date of birth
Are you at least 18 years old?
Yes
No
If you selected Prefer to self-describe, please specify (optional)
Email address
Mobile phone number
Emergency contact full name
Emergency contact phone
Emergency contact relationship to you
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Do you have any of the following conditions? (Select all that apply)
Please Specify:
Allergies (Select all that apply)
Botulinum toxin
Lidocaine or local anesthetics
Egg albumin or human albumin
Latex
Adhesives or tapes
No known allergies
Other
Please Specify:
If Other allergies, please specify
Current medications or supplements (Select all that apply)
Please Specify:
Please list all current medications and supplements with doses (include start dates if known)
Are you currently pregnant?
Yes
No
Are you currently breastfeeding?
Yes
No
Are you planning to become pregnant in the next 3 months?
Yes
No
Do you have any active infection, rash, or cold sore at or near the treatment area?
Yes
No
Do you bruise or bleed easily?
Yes
No
Have you had facial surgery, lasers, or chemical peels within the last 3 months?
Yes
No
Date of most recent botulinum toxin treatment (if applicable)
If you experienced any issues or unsatisfactory results from prior treatments, please describe
Have you previously had botulinum toxin injections (e.g., Botox, Dysport, Xeomin, Daxxify)?
Yes
No
Areas you wish to treat today (Select all that apply)
Please Specify:
Primary goals or concerns for this treatment
Do you consent to topical anesthetic if needed?
Yes
No
Do you consent to before/after photos for your medical record?
Yes
No
Do you consent to use of de-identified photos for education or marketing?
Yes
No
I have received information about the botulinum toxin injection procedure.
Yes
No
I understand common side effects may include temporary redness, swelling, bruising, tenderness, or headache.
Yes
No
I understand rare risks may include eyelid or brow drooping (ptosis), asymmetry, dry eye, infection, or allergic reaction.
Yes
No
I understand results are temporary.
Yes
No
I understand individual results may vary and touch-ups may be needed.
Yes
No
I am aware of alternatives such as no treatment, skincare, lasers, peels, or surgery.
Yes
No
I agree to follow all aftercare instructions provided.
Yes
No
I acknowledge there is no guarantee of specific results.
Yes
No
I acknowledge this is an elective procedure and costs are my responsibility.
Yes
No
I authorize the clinician to perform botulinum toxin injections today.
Yes
No
Do you consent to be contacted by phone, text, or email for appointment reminders or follow-up?
Yes
No
Treating clinician name
Product lot number and expiration date
Injection sites and total units administered
Patient signature (type full legal name)
Date signed
{"name":"Full legal name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full legal name, Date of birth, Are you at least 18 years old?","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration representing a Botox consent form template for FormCreatorAI article.

When to use this form

Use this template any time you need informed consent before cosmetic or therapeutic Botox injections. It fits med spas, dermatology and plastic surgery clinics, and neurology practices treating chronic migraine or spasticity. Send it before the visit to screen for contraindications, allergies, and medications; at the chair, it documents risks, benefits, alternatives, and aftercare, then captures a signature. For remote intakes or paperless workflows, pair it with the Electronic informed consent form. If the treatment is part of a study, add the Research consent form to cover study-specific disclosures. For eligible therapeutic patients who need help with medication costs, point them to the Botox patient assistance program application form.

Must Ask Botox Consent Questions

  1. Do you have any medical conditions, neuromuscular disorders, or recent facial procedures?

    This surfaces contraindications (for example, myasthenia gravis, infection, or recent surgery) and helps you time treatment safely. Clear history lowers complication risk and guides dosing.

  2. Are you pregnant, trying to conceive, or breastfeeding?

    Botulinum toxin is not recommended in these situations, so this determines whether to proceed or defer. Documenting this status protects patient safety and your compliance.

  3. Have you had Botox or similar botulinum toxin treatments before, and did you have any reactions?

    Past response, duration of effect, or adverse events (such as eyelid ptosis or headache) inform product choice and units. It prevents over- or under-treatment and flags possible resistance.

  4. Which areas do you want treated, and what results are you expecting?

    This aligns goals, maps injection sites, and sets realistic timelines. It reduces dissatisfaction by clarifying limits, asymmetries, and the need for touch-ups.

  5. Do you understand the risks, benefits, alternatives, costs, and aftercare, and do you consent to treatment today?

    This confirms informed consent and creates a clear record for clinical and legal standards. It also ensures the patient knows aftercare to reduce bruising, swelling, or toxin spread.

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