Name * First Name Last Name Email * Phone (###) ### #### Address Emergency Contact Name Phone 1. Are you pregnant, nursing, or planning to become pregnant? Yes No 2. Do you have a history of allergies to botulinum toxin (e.g., Botox,Innotox, Nabota , Coretox, Xeomin)? Yes No 3. Have you ever experienced an adverse reaction to a cosmetic procedure? Yes No 4. Do you have any of the following conditions? (Check all that apply): Neuromuscular disorders (e.g., Myasthenia Gravis, ALS) Skin infections or rashes near the treatment area Difficulty swallowing, speaking, or breathing issues Bleeding disorders or conditions affecting blood clotting 5. Are you currently taking any of the following? Blood thinners (e.g., aspirin, warfarin) Muscle relaxants Allergy or cold medications Antibiotics (recent or ongoing use) 6. Do you have any upcoming medical, dental, or cosmetic procedures scheduled? Yes No 7. Do you smoke or drink alcohol regularly? Yes No 8. Do you bruise easily? Yes No What areas are you interested in treating today? (Check all that apply): Forehead lines Crow’s feet Frown lines (11s) Bunny lines (nose wrinkles) Lip lines (smoker’s lines) Chin dimpling Jawline slimming/teeth grinding (masseters) Neck bands Other: What results are you hoping to achieve? 3. Are you aware that Botox results are temporary and typically last 3-4 months? Yes No Thank you!
