Cosmetic Procedure Consent · Popular

Botox & Dermal Filler Informed Consent Form

Streamline patient intake and consent for Botox and dermal filler treatments with this comprehensive, ready-to-use form template.

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Botox & Dermal Filler Treatment Informed Consent Form

Patient Full Name

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Date of Birth

· · ·

Phone Number

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Submit

The Botox & Dermal Filler Treatment Informed Consent Form is a professional template designed for medical spas, dermatology clinics, and cosmetic practices. It captures essential patient information including medical history, known allergies, current medications, and prior treatment experience—everything your team needs to provide safe, personalized care.

This form is ideal for licensed injectors, aesthetic nurses, dermatologists, and plastic surgeons who want to ensure full patient transparency before administering botulinum toxin or filler treatments. It covers treatment areas, requested procedures, emergency contact details, and critical health screening questions such as pregnancy status and allergy disclosures.

By using this digital consent form, your practice reduces liability, improves documentation accuracy, and delivers a professional experience to every patient. Customize it to match your clinic's branding and compliance requirements, then share it online or embed it directly on your website for easy pre-appointment completion.

4 Pages

35 Questions

~12min To complete

Free No credit card needed

Field types singlecheckbox ×7 Short Text ×4 Long Text ×4 richtext ×4 Date ×3 Yes / No ×3 Phone ×2 Multiple Choice ×2 Signature ×2 Full Name Email Address termsandconditions

Questions in this template

Free template

The exact questions included — customize any of them to fit your needs.

Page 1 Patient Information 8 questions

Patient Information

1 Patient Full Name * Full Name

2 Date of Birth * Date

3 Phone Number * Phone

4 Email Address * Email

5 Home Address * Address

6 Emergency Contact Name * Short Text

7 Emergency Contact Phone Number * Phone

8 Referring Physician / How Did You Hear About Us? Short Text

Page 2 Medical History & Treatment Details 10 questions

Medical History

1 Are you currently pregnant or breastfeeding? * Yes / No

2 Do you have any known allergies to botulinum toxin, lidocaine, or any dermal filler components? * Yes / No

3 Please list all known allergies (medications, food, latex, etc.) Long Text

4 Do you have a history of any of the following conditions? * Multiple Choice

5 Please list all current medications, vitamins, and supplements (including blood thinners, aspirin, NSAIDs) * Long Text

6 Have you previously received Botox or dermal filler treatments? * Yes / No

7 If yes, please describe previous treatments, dates, areas treated, and any complications experienced Long Text

Treatment Details

8 Treatment(s) Requested * Multiple Choice

9 Treatment Area(s) — Please specify all areas to be treated (e.g., forehead, glabella, crow's feet, nasolabial folds, lips, cheeks, jawline) * Long Text

10 Treating Practitioner Name * Short Text

Page 3 Risks, Benefits & Consent Acknowledgment 9 questions

Understanding of the Procedure

1 <strong>Botox (Botulinum Toxin):</strong> Botox is a purified protein injected into targeted muscles to temporarily reduce or eliminate fine lines and wrinkles. Results typically appear within 3–14 days and last approximately 3–6 months. Repeat treatments are necessary to maintain results. richtext

2 <strong>Dermal Fillers:</strong> Dermal fillers are injectable gels (commonly hyaluronic acid-based) used to restore volume, smooth wrinkles, and enhance facial contours. Results are immediate to near-immediate and may last 6–24 months depending on the product and treatment area. richtext

Potential Risks & Side Effects

3 All medical procedures carry risks. Potential risks and side effects of Botox and dermal filler treatments include but are not limited to: pain, swelling, redness, or bruising at the injection site; headache; itching or rash; infection; asymmetry or uneven results; allergic reaction; numbness or tingling; nodules or lumps under the skin; migration of product from the injection site; tissue necrosis (death of skin tissue) due to vascular occlusion; vision changes or blindness (rare, with filler); muscle weakness or drooping (ptosis); difficulty swallowing or breathing (rare, with Botox); unsatisfactory aesthetic results requiring additional treatment or correction. richtext

Patient Acknowledgments

4 I confirm that I have been informed of the nature of the proposed treatment(s), including the expected benefits, potential risks, side effects, and possible complications. * singlecheckbox

5 I understand that results are not guaranteed and may vary. Additional treatments may be needed to achieve desired outcomes, possibly at additional cost. * singlecheckbox

6 I confirm that I have disclosed my complete medical history, including all medications, supplements, allergies, and prior cosmetic treatments. * singlecheckbox

7 I understand that I should avoid blood-thinning medications, alcohol, and strenuous exercise as advised before and after treatment, and I agree to follow all pre- and post-treatment care instructions provided. * singlecheckbox

8 I acknowledge that photographs may be taken before and after treatment for my medical record. These images will not be used for marketing purposes without my separate written consent. * singlecheckbox

9 I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction. * singlecheckbox

Page 4 Consent & Signature 8 questions

Consent Declaration

1 By signing below, I voluntarily consent to the Botox and/or dermal filler treatment(s) described in this form. I acknowledge that I have read, understand, and agree to the information provided herein. I release the treating practitioner and clinic from liability for any outcomes consistent with the known risks described above. richtext

2 I confirm that I am at least 18 years of age and am providing this consent voluntarily and without coercion. * singlecheckbox

3 I have read and agree to the full terms of this Informed Consent for Botox & Dermal Filler Treatment. * termsandconditions

Patient Signature

4 Patient Signature * Signature

5 Date of Consent * Date

Practitioner Declaration

I confirm that I have explained the proposed treatment, its risks, benefits, alternatives, and have answered all patient questions.

6 Practitioner Name * Short Text

7 Practitioner Signature * Signature

8 Date * Date

How to use this template

Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.