Read this before you use it
Botulinum toxin is a prescription medical treatment. This template must be reviewed and adapted by the prescribing practitioner and your indemnity insurer before use, and it must reflect the law where you operate. Prescribing rules, who may inject, and what consent must contain all vary significantly by jurisdiction.
The form carries that warning as its first block, on the page, so nobody downstream mistakes a downloaded template for a compliant one.
Screening, risks and the treatment record
Patient details including GP. A medical screening list covering the contraindications specific to botulinum toxin: pregnancy or breastfeeding, neuromuscular disorders, previous allergic reaction to the toxin or to albumin, bleeding disorders or anticoagulants, active infection at the site, aminoglycoside antibiotics or muscle relaxants, autoimmune conditions, and previous facial surgery or implants. Then medications, allergies, history and previous treatments with product and date.
A risk acknowledgement table with nine rows, each initialled by the patient.
A treatment record: product and brand, batch number, expiry, dilution, then a per-area table capturing treatment area, units, injection points and notes, with total units, prescribing practitioner and injector recorded separately.
Aftercare, then a consent block, then dual signature.
Why the risks are a table you fill in
The risk table is deliberately blank, with a note listing what is typically discussed rather than pre-printing the risks into the rows.
A pre-printed list with one signature at the bottom evidences that a document was signed. An initial against each line evidences that each item was discussed with this patient.
The note tells you what typically belongs there: bruising, swelling, tenderness, headache, asymmetry, eyelid or brow droop, temporary weakness of nearby muscles, treatment failure or reduced effect over time, the two-week review, and that results are temporary.
Batch numbers are not administrative detail
Product, brand, batch number, expiry and dilution all have their own fields, and the treatment table records units per area rather than a single total.
Two reasons. If a product recall occurs, you need to identify every patient treated from an affected batch, and you cannot do that from a total dose written on a consent form. And if a patient returns reporting an unusual outcome, the per-area unit record is what lets you work out what happened rather than reconstructing it from memory.
Prescriber and injector are recorded separately because in many jurisdictions they are different people with different responsibilities, and a single "practitioner" field obscures that.
Photography consent is separated
The consent block includes agreement to clinical photographs for the medical record. Marketing use is a separate tick with separate written consent required.
Bundling them is common and it is a mistake. A patient consenting to a clinical photograph for their file has not consented to appearing on your social media, and treating one signature as covering both is the kind of thing that produces a complaint with no defence.