About this template
Streamline patient intake and ensure legal protection with this comprehensive Botox and Filler Consent Form. Designed specifically for medical spas, dermatologists, and aesthetic clinics, this template collects essential patient information, detailed medical history, potential contraindications, and acknowledged treatment risks prior to cosmetic injectable procedures.
By gathering health histories, allergy disclosures, and lifestyle factors upfront, practitioners can safely evaluate patient eligibility for neurotoxins and dermal fillers. The form also covers vital safety disclosures, ensuring patients are fully informed about expected outcomes, potential side effects, and post-procedure care instructions.
Built for seamless digital use with Doc2Form, this template allows patients to complete their paperwork ahead of time on any smartphone, tablet, or computer. Say goodbye to clipboards and paper clutter, and keep your client records organized and accessible in your digital workspace.
Key features
- Collect complete medical history and allergy disclosures before treatment.
- Screen for contraindications specific to botulinum toxin and dermal fillers.
- Securely document patient acknowledgment of treatment risks and side effects.
- Mobile-friendly format allows patients to complete forms easily from home.
- Instantly save and organize all responses in your connected digital storage.
Use cases
Initial consultations at medical spas and aesthetic clinics.
Pre-treatment screening for new patients receiving neurotoxin injecti…
Pre-treatment screening for new patients receiving neurotoxin injections.
Dermal filler procedure risk disclosure and consent documentation.
Annual patient medical history and consent updates.
What this form collects
- Full Legal Name (Short answer)Enter your first, middle, and last name.
- Date of Birth (Date)Please provide your birth date.
- Phone Number (Short answer)Best number to reach you regarding your appointment.
- Email Address (Short answer)Where we can send your appointment confirmation and aftercare instructions.
- Home Address (Paragraph)Street address, city, state, and ZIP code.
- Medical History & Conditions (Checkboxes)Select any conditions that currently apply to you.
- Known Allergies (Paragraph)List any allergies to medications, lidocaine, latex, or previous cosmetic products.
- Current Medications & Supplements (Paragraph)List any blood thinners, aspirin, NSAIDs, herbal supplements, or prescription drugs you currently take.
- Are you currently pregnant, trying to conceive, or breastfeeding? (Multiple choice)Cosmetic injectables are typically contraindicated during pregnancy and lactation.
- Have you had any cosmetic facial treatments or surgery in the past 6 months? (Paragraph)Include lasers, chemical peels, threads, or previous filler treatments in the treatment area.
- Consent Acknowledgment (Multiple choice)Please read carefully before signing. I understand the potential risks, side effects, and expected results of Botox and dermal filler procedures. I confirm that the medical history provided is accurate to the best of my knowledge.
- Patient Signature (Type Full Name) (Short answer)Typing your full name here serves as your digital signature and confirmation of consent.
FAQ
What is the purpose of a cosmetic injectable consent form?
It ensures patients are fully informed about the risks, benefits, and realistic outcomes of treatments like Botox and fillers, while documenting their medical history to ensure they are safe candidates for the procedure.
Can I customize the medical questions and contraindications?
Yes! Once you convert this template using Doc2Form, you have full control in Google Forms to add, remove, or edit any questions to match your clinic's specific protocols.
How do patients sign this form electronically?
Patients can fill out the form online prior to their appointment. For signature collection, you can include a dedicated text field for their legal name and date, or use an integrated signature tool.
Is this template suitable for mobile devices?
Yes, Google Forms automatically optimizes layout and formatting so patients can complete their paperwork smoothly on phones, tablets, or computers.
How can I access completed patient responses?
All submissions are instantly compiled in a connected Google Sheets spreadsheet, making it easy to review patient records and attach them to your practice management system.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.