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
Use This Form Digitally
Paper forms work, but digital forms work better. Here is what you get when you use this template on CheckinPulse:
Clients fill out on their phone (no app needed)
Scan a QR code or tap a link — works on any device
E-signatures with legal timestamp
IP address, timestamp, and audit trail on every signature — valid in all 50 states under the E-SIGN Act
Submissions go straight to your dashboard
No more clipboards, filing cabinets, or illegible handwriting
PDF waivers stored for 7 years
Encrypted, searchable, and accessible anytime on paid plans
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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
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.
Legal References
The federal law that makes electronic signatures on consent forms and waivers legally equivalent to handwritten signatures in all 50 US states.
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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