Botox Intake and Consent Form

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Address
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Sex

Please List Your Primary Care Physican

List Any Other Physicans You See

Medical History

Have You Had Any Of The Following Conditions?
Has Any Member Of Your Family Had Any Of The Following Conditions?

Previous Surgeries

Current Prescription Medications

Current Non-Prescription Medications

(Including Herbals & Supplements)

Please List All Allergies

Signature
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Botulinum Toxin Informed Consent Section

Patient Name
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Schedule A Consultation

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