Name(Required) First Last Date of birth(Required) MM slash DD slash YYYY Gender Female Male Prefer not to say Phone(Required)Email(Required) Address(Required) Street Address Address Line 2 City ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Medical HistoryAre you currently under the care of a physician or receiving any medical treatment? Yes No If yes, please specify. Do you have any allergies (e.g., medications, cosmetics, latex, etc.)? Yes No If yes, please specify. Have you had any recent surgeries, injuries, or any other medical procedures? Yes No If yes, please specify. Are you currently taking any medications or supplements? Yes No If yes, please specify. Have you ever had any adverse reactions to beauty treatments (e.g., allergic reactions, infections)? Yes No If yes, please specify. Are you pregnant, breastfeeding, or trying to conceive? Yes No Do you have any bleeding disorders or take blood-thinning medications? Yes No Skin HistoryDescribe your skin type (e.g., oily, dry, combination). Oily Dry Combination Have you ever been diagnosed with any skin conditions (e.g., acne, eczema, rosacea, psoriasis)? Yes No If yes, please specify. Do you have any existing skin concerns or areas you would like to focus on during the treatment?Have you undergone any previous cosmetic procedures (e.g., chemical peels, laser treatments)? Yes No If yes, please specify. Do you have any tattoos or permanent makeup on the treatment area? Yes No If yes, please specify. Botox Treatment HistoryHave you had Botox treatment before? Yes No If yes, please specify where and when. Are you currently receiving any other beauty treatments or planning to have any in the near future? Yes No If yes, please specify. Are you using any at-home skincare products or following a specific skincare routine? Yes No If yes, please specify. Are you aware of any potential side effects or downtime associated with Botox treatment? Yes No If yes, please specify Are you currently experiencing any muscle or nerve-related conditions (e.g., ALS, Lambert-Eaton syndrome, myasthenia gravis)? Yes No Do you have any known neuromuscular disorders or swallowing difficulties? Yes No Have you had any recent facial surgeries or treatments in the treatment area (e.g., chemical peel, dermal filler injections)? Yes No Is there anything else you would like to share or any questions you have regarding the Botox treatment?By signing this consultation form, I acknowledge that I have provided accurate and complete information to the best of my knowledge. I understand that the effectiveness and safety of the beauty treatment, including Botox treatment, depend on the accuracy of the information provided. If I fail to disclose any relevant medical conditions, medications, allergies, or other pertinent information, I acknowledge that the beauty treatment may carry additional risks and complications. I understand that the beauty treatment provider relies on the information provided to make informed decisions regarding the treatment plan. If I withhold or provide incorrect information, I assume responsibility for any adverse effects or consequences that may arise during or after the treatment. The beauty treatment provider and their staff will not be held liable for any complications, injuries, or dissatisfaction resulting from incomplete or inaccurate information provided by me. I have read and understood the above disclaimer, and I willingly accept the responsibility for providing accurate and complete information for the beauty treatment.SignatureConsent I agree to the privacy policy. Δ