BOTOX® Patient Consent Form

Updated September 30, 2021

A BOTOX (also known as botulinum toxin) patient consent form is utilized to inform a patient seeking BOTOX of the risks of the cosmetic procedure, as well as its potential complications, side effects, and financial requirements. The consent form gives a medical provider the ability to perform the BOTOX treatment and is a legally binding form that is signed by the patient receiving treatment.

What is Included?

  • Name of medical facility or medical practitioner receiving consent
  • Written patient name
  • Description of the treatment
  • Potential complications, risks and side effects
  • Financially responsible party for treatment
  • Payment terms and requirements
  • Disclaimer regarding before and after pictures
  • Disclaimer regarding no guarantees are made for the procedure
  • Clause disclosing facility and/or practitioner is not held liable for negative complications or issues resulting from the BOTOX
  • Signed patient name
  • Date of signature

How to Use a BOTOX Patient Consent Form

1. Become informed about Botulinum toxin

Prior to undergoing a cosmetic treatment, the patient should further consult a medical provider for understanding of what BOTOX is and how it is administered. Additional information should be provided in terms of effectiveness and lasting effects.

2. Know risks and complications

Any known risks, complications or side effects should be provided to the patient undergoing treatment. A full list of side effects may not be listed on the consent form and it will be the patient’s responsibility to consult with their provider if they have further concerns regarding risks, side effects or common complications.

3. Check with your doctor

Patients should consult with their Primary Care Managers to ensure they are eligible candidates for BOTOX. A patient’s medical history will need to be reviewed to ensure there are no additional or higher risks of side effects prior to undergoing cosmetic treatment.

4. Sign and prepare for procedure

A person who is interested in BOTOX should review the form and ensure all questions are answered prior to signing the form. Once they have full understanding the patient should sign and date the form and provide it to their medical practitioner prior to the procedure.

Common BOTOX side effects

The list below is list of most common side effects however it does not list each potential side effect. A patient interested in receiving BOTOX should consult a healthcare provider for further information regarding side effects.

  • Nausea
  • Headache
  • Bruising
  • Development of antibodies to the BOTOX
  • Symptoms resembling the flu
  • Permanent loss of muscle tone (due to repeated injections)
  • Generalized weakness all over the body
  • Facial asymmetry (causes one side of the face to look different than the other)
  • Under correction or overcorrection
  • Paralysis of nearby muscles which can further cause double vision, droopy eyelid, inability to close eye, difficulty whistling or drinking through a straw.
  • Inability to speak
  • Trouble breathing