Know the boundaries
Not for: Other toxin brands, therapeutic injections, dosing instructions or a substitute for the current Medication Guide.
Source-checked template, version 2.0, September 21, 2026. Practice review and adaptation are required before use. No independent clinician or attorney approval is claimed. Adult patient self-consent only; use a separately reviewed process for minors or representatives.
Inside the template
Two clean, unbranded patient-facing pages: the relevant discussion, specific choices and completion fields, and the patient decision with signatures. The PDF includes fillable fields and selection controls where applicable. Use the Word version to adapt the language. Sources and practice guidance stay on this page. 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
Injection effects
Pain, tenderness, bruising, swelling or redness at injection sites can occur. Headache and unsatisfactory or uneven results are possible.
Nearby muscle and eye effects
Unwanted weakness may cause a drooping eyelid or brow, changes in expression, difficulty closing an eye, dryness or other eye symptoms. The pattern and duration depend on the treated area and individual response.
Serious reactions
Allergic reactions and spread of toxin effects can occur. The boxed warning describes potentially life-threatening swallowing or breathing problems, including reported deaths. Symptoms can develop hours to weeks after injection.
Details to complete before signing
- Practice name
- Visit / discussion date
- Patient full name
- Date of birth
- Treating clinician
- Treatment date
- Exact product / device, planned treatment areas and intended benefit
- Patient labeling / instructions reviewed (version)
- Proposed use: labeled / off-label (explain)
- Any off-label use and its reason, uncertainties and alternatives discussed
- Relevant history, medicines, allergies and patient-specific risks / plan
- Alternatives discussed and patient questions / answers
- Written aftercare / patient information supplied
- Follow-up plan
- Urgent practice contact
- After-hours contact / instructions
- Patient signature
- Date / time
- Clinician / practice representative name
- Signature / date
- Interpreter name / ID if used
- Language
- Copy of completed consent provided by
- 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.