Your Name & Surname (required)
Your Email
Medical History (incl Porphyria)
Medication taken regularly/currently
Are you pregnant/trying to fall pregnant or breastfeeding? YesNo
Previous cosmetic procedures: Specify Type used and complications if any Botulinum Toxin Fillers Threads Peels Surgery
Are you prone to: KeloidsScarringBruising
Please read the following and discuss any uncertainties with the dermatologist BEFORE signing consent to perform the procedure:
I have been informed about alternative treatments and cosmetic procedures such as surgery, laser and filler treatments
I have received and read the pre- and post treatment check list
I understand the procedure that will be performed
I have no conditions listed as contra-indications
I had adequate time to consider my decision and understand that I can reconsider at any time prior to the treatment.
By placing my signature below, I declare my consent to cosmetic treatment with Botulinum Toxin (Botox)
Patient:
Date:
Signature:
This is not an actual appointment form. The below form is to request an appointment, we will get back to you to confirm if the requested date and time is available.
Your Name (required)
Your Email (required)
Your Cell Number (required)
Date & Time
Your Message
