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Botox Consent Form

Informed consent form for Botox and neurotoxin injections. Covers risks, contraindications, expected results, and post-procedure instructions.

Last updated: April 2026

Researched by the CheckinPulse Research Team

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This is what your clients will fill out. 18 fields, mobile-friendly.

Botox Consent Form

All fields marked with * are required

Jane Doe
jane@email.com
(555) 123-4567
Date
Text
Phone
Forehead Lines
Yes
Approximate date
Include blood thinners, antibiotics, muscle relaxants...
Botulinum toxin, albumin, latex...
Yes
Yes
I understand that results are temporary (3-4 months) and outcomes may vary*
I understand the risks including bruising, asymmetry, headache, and rare complications*
I consent to before and after photos for my medical records
Sign here
Submit Form

Consent / Waiver Language

This waiver text is included at the bottom of the form, above the signature field.

I consent to the injection of botulinum toxin (Botox, Dysport, Xeomin, or equivalent) in the treatment area(s) described above. I understand that: (1) Results typically appear within 3-14 days and last 3-4 months; (2) Risks include bruising, swelling, headache, asymmetry, ptosis (eyelid drooping), and rare allergic reactions; (3) The treatment is contraindicated during pregnancy and nursing, and for patients with neuromuscular disorders; (4) I should avoid lying down for 4 hours post-treatment and avoid strenuous exercise for 24 hours; (5) Touch-up injections may be needed and are not guaranteed to be included. I have disclosed all medications, allergies, and medical conditions. I release the provider from liability for outcomes within the normal range of expected results.

Frequently Asked Questions

Yes, in virtually all states. Botox is a prescription medication (botulinum toxin) and informed consent is required before any injection. The form must cover risks, expected outcomes, alternatives, and contraindications. Without it, you're exposed to malpractice liability even if nothing goes wrong.

The main ones: bruising (happens to about 25% of patients), swelling, headache, asymmetry, ptosis (eyelid drooping, occurs in roughly 1-2% of cases), allergic reaction, and the fact that results are temporary. For masseter injections, add jaw weakness as a risk.

This varies by state. In most states, NPs and PAs can inject Botox under physician supervision (which may be remote/collaborative). Some states allow independent NP practice. Your consent form should name the actual injector and their supervising physician if applicable.

Best practice is once per year, or whenever the treatment area changes. Some practices have patients sign at every visit — it only takes a minute digitally and keeps your records airtight.

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