Botox Patient Application
General
First Name:
Last Name:
Date:
Address:
City:
State:
Zip Code:
Phone Home:
Phone Work:
Phone Cell:
Date of Birth:
Marital Status:
Age:
Employer:
Occupation:
Emergency Contact:
Relationship:
Emergency
Phone Home:
Emergency
Phone Work:
Emergency
Phone Cell:
Email Address:
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Health History
Medications:
(prescription and over the counter; vitamins, herbal medications)
Allergies:
Surgeries
/Dates:
Have a history of?
Heart Disease
Mental Disease
Neuro-muscular Disease
Excessive Bleeding
Auto-immune Disorders
Diabetes
High Blood Pressure
Liver Disease
Cold Sores/Fever Blisters
Other
Please explain:
Are you?
Pregnant:
Yes
No
Nursing:
Yes
No
Do you?
Smoke:
Yes
No
Drink Alcohol:
Yes
No
Amount per day:
Post Treatment Instructions
DO:
Remain upright for 4 hours after injection
Exaggerate facial expressions in injected areas for 1 hour after injection
Call the office immediately if you experience any problems or have any questions
Schedule your follow up appointment prior to leaving office
DO NOT:
Take ibuprofen, aspirin or vitamin E for 24 hours after injection
DO NOT massage or manipulate injection sites for 48 hours after injection
Results are expected within 24 hours to one week after injection
The above information is true and accurate to the best of my knowledge.
Patient Signature:
Date:
Witness Signature:
Date: