Botox / Neuromodulator Consultation & Pre-Treatment Intake

Fill this out before your visit. Review the completed form, then sign and send.

Patient information

Full legal name

Date of birth

Age

Sex

Home address

City

State

ZIP code

Primary phone number

Secondary phone number

Email address

Emergency contact name

Emergency contact relationship

Emergency contact phone number

Primary care provider

Primary care provider address

Primary care provider phone number

Allergies

Do you have any allergies?

Vaccinations

Have you received any vaccinations in the last two weeks (14 days)?

Herpes Simplex Virus (HSV) history

HSV is a common viral infection that may cause cold sores or fever blisters. Treatment around the face may occasionally trigger an outbreak in individuals with a history of HSV.

Date of most recent outbreak

Frequency of outbreaks

Are you currently taking antiviral medication?

Patient acknowledgment

I certify that the information provided above is complete and accurate to the best of my knowledge. I understand that withholding medical information may increase the risk of complications or adverse reactions.

I understand that the provider may determine I am not an appropriate candidate for Botox or neuromodulator treatment based on my medical history, medications, anatomy, or other factors.

Acknowledgment

I certify the above information is complete and accurate to the best of my knowledge.

Patient signature

Date

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Botox / Neuromodulator Consultation & Pre-Treatment Intake

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