Know the boundaries
Not for: Other toxin brands, therapeutic injections, dosing instructions or a substitute for the current Medication Guide.
Source-checked educational draft, version 1.0, September 20, 2026. Not reviewed or approved by an attorney or clinician. A qualified professional must adapt and approve it for the practice, jurisdiction, patient and actual service before use. A signature does not replace an informed discussion. Adult templates only; not a minor or proxy-consent workflow.
Inside the template
Five pages: practice preparation, patient discussion, two completion pages, and an implementation/source appendix. The PDF has fillable text fields; use the Word version to revise the language. Typed fields are not a verified electronic-signature service.
Actual sample page · Open to enlarge · Full editable files available below
Prepare your practice version
- Confirm the actual product and whether the planned use matches its labeling.
- Give the current Medication Guide and discuss its warning and contraindications.
- Review prior toxin treatment, medicines, allergies and relevant health history.
- Document individualized risks, alternatives, aftercare and the opportunity to decline.
Public text preview
Language for the conversation
Proposed treatment
BOTOX Cosmetic temporarily reduces activity in treated muscles. My clinician will identify the planned area and intended improvement below, and explain whether the proposed use is within the current product labeling.
Risks to discuss
Risks include injection discomfort, bruising, headache, drooping eyelid or brow, asymmetry, eye symptoms and allergic reactions. Effects can spread beyond the injection area. Trouble breathing, speaking or swallowing may be life-threatening and requires immediate medical attention. My clinician will discuss the current boxed warning and risks relevant to me.
History and product review
Tell the clinician about prior reactions, injection-site infection, muscle or nerve conditions, swallowing or breathing problems, eye symptoms, pregnancy or breastfeeding, medicines and recent toxin treatment. BOTOX Cosmetic units are not interchangeable with other toxin products. The clinician must evaluate contraindications and the complete current labeling before proceeding.
Details to complete before signing
- Patient name
- Practice / treating clinician
- Exact product or device and treatment area
- Treatment goal and anticipated benefit
- Labeling / patient information version supplied
- Patient-specific risks and relevant history reviewed
- Alternatives discussed, including no treatment
- Questions and answers / additional agreed limits
- Aftercare instructions and follow-up plan reference
- Practice urgent contact / after-hours route
- Patient signature and date / time
- Clinician signature and date / time
- Copy supplied: date / method
Common questions
Can this form be used for Dysport or Xeomin?
No. This draft identifies BOTOX Cosmetic. Do not substitute a brand name without reviewing the actual product labeling and revising the discussion and consent.
Does the template provide injection doses?
No. It supports documentation of the consent conversation, not treatment selection or administration.