Surveypoint

Q1

Patient Name

First Name

Q2

Patient Name

Last Name

Q3

Date of Birth

Date

Q4

Address

Street Address

Q5

Address

Street Address Line 2

Q6

Address

City

Q7

Address

State / Province

Q8

Address

Postal / Zip Code

Q9

Are you currently taking any medical or dental treatment?

Yes

No

Q10

Please list them

Q11

In the last one month, have you had any dermal treatments such as tattoos, dermal fillers, piercings or botulinum toxin?

Q12

Please give details

Q13

Do you have any relevant past medical history

Q14

Have you recently received your COVID-19 vaccination?

Yes

No

Q15

Are you pregnant or breast feeding?

Yes

No

Q16

Do you have any allergies in your knowledge?

Yes

No

Q17

Did you get any aesthetic treatments before?

Yes

No

Q18

Please select if you suffer from any of the conditions listed below

Q19

Botulinum Toxin Treatment Consent Form -Form Fill

Patient Name

Patient Name

Date of Birth

Address

Address

Address

Address

Address

Are you currently taking any medical or dental treatment?

Please list them

In the last one month, have you had any dermal treatments such as tattoos, dermal fillers, piercings or botulinum toxin?

Please give details

Do you have any relevant past medical history

Have you recently received your COVID-19 vaccination?

Are you pregnant or breast feeding?

Do you have any allergies in your knowledge?

Did you get any aesthetic treatments before?

Please select if you suffer from any of the conditions listed below

Additional details you want to give