Do we need to be discreet with messages?
May we contact you via e-mail/text message?
Female patients: Are you or could you be pregnant or nursing?
Do you experience easy or excessive bruising/ bleeding?
Have you had any reaction to any type of anesthetic- dental/surgery?
Do you or any family member suffer from the following neurological disorders:
Amyotrophic Lateral Sclerosis (ALS)
Do you have any semi-permeant filler in your face (Bio-Alcamid, Dermalive, Dermadeep, Beauticall, Artecoll, or Artesense)?
Select if you have or have had any issues with the following:
Select any of the following which you presently have or have had:
Do you have or had any other diseases or medical problems not listed on this form?
Do you have any allergies? If yes, please list using the category below:
Have you been treated with Dysport, Botox or Xeomin?
Have you been treated with Hyaluronic Acid Fillers?
I HEREBY ACKNOWLEDGE THAT I HAVE FULLY DISCLOSED, TO THE BEST OF MY KNOWLEDGE, MY COMPLETE MEDICAL HISTORY AND HAVE ANSWERED ALL OF THESE QUESTIONS AS HONESTLY AND COMPLETELY AS POSSIBLE. NEITHER THE NURSE PRACTITIONER, NOR THEIR NURSE, ARE RESPONSIBLE FOR ANY ADVERSE EVENTS THAT OCCUR AS A RESULT PF FAILURE TO DISCLOSE HEALTH INFORMATION AS REQUESTED.
I acknowledge that I have had the opportunity to consult with the Nurse Practitioner to ask any questions that I may have related to the procedure I am about to undergo. The Nurse Practitioner has reviewed my health history and medications with me and I agree that I have not withheld any medical information from them or their associates.
I acknowledge that delegation of this injection to the Registered Nurse by the Nurse Practitioner.