Consent · free template

Botox Consent Form

A Botox treatment consent form covering medical history screening, treatment areas, risks discussed and the patient's signed informed consent.

A ready-to-use consent, waivers & releases form for any team that needs demonstrable permission: 15 questions, 2 pages, 3 conditional rules.

Questions: 15
Pages: 2
Layouts: classic · card
Time to complete: ≈ 6 min
Conditional rules: 3

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Live preview and test console

This is the real form. Answer it to test the 3 conditional rules — nothing is sent or stored.

Page 1 of 2 — Medical history

2 questions are hidden by conditional logic right now — change an answer above to reveal them.

Ready to publish

Payment items priced — passingEvery payment question charges a real amount, so a submission always records a payment.
Conditional logic resolves — passingEvery rule points at a question or page that exists in this template.
Medical disclaimer present — passingThis form does not provide medical advice, diagnosis or treatment. Information you share here is not a substitute for care from a qualified clinician. In an emergency, contact your local emergency service immediately.
Question labels unique — passingLogic and exports address questions by label, so duplicates are ambiguous.

What happens after submit: nothing is stored in this preview. On your own copy, every response triggers an instant email notification and lands in your response dashboard, ready to export or forward.

Happy with it? Take a copy into your workspace — every question, rule and setting comes with it.

Who this template is for

Botox Consent Form is built for any team that needs demonstrable permission who need to record who agreed to what, and when.

Any team that needs demonstrable permission working in consent, waivers & releases.
Teams who need to record who agreed to what, and when without writing code or paying for a custom build.
Anyone replacing consent claims you can't evidence months later with one structured record per enquiry.
Respondents are customers, patients and participants — the form asks them 15 questions across 2 screens.
Mobile-heavy audiences, thanks to the one-question-per-screen card layout.

Why this form is useful

It removes the cost of consent claims you can't evidence months later and turns each submission into a record your team can act on immediately.

11 questions are required, so submissions arrive complete instead of needing a follow-up email.
It records a signature you can keep as proof of agreement.
It pins the request to a specific date.
It allows multiple selections without free text.
Conditional logic hides 3 questions until they are relevant — shorter forms convert better than long ones.
Splitting the form across 2 pages keeps each screen short and shows respondents how much is left.
Every response is stored, searchable and exportable, so nothing depends on one person's inbox.

How to use this template

From copy to live form is a few minutes of work, and every step is reversible.

1Press “Use this template” — a fresh copy of Botox Consent Form lands in your workspace, ready to edit.
2Rename or delete any question, and change what is required. Nothing here is fixed.
3Open Notifications and add the email addresses that should be alerted on each submission; add an auto-reply to the respondent if the form collects an email address.
4Publish it, then either share the link directly or paste the embed snippet into your site — the embedded form resizes to fit and loads no marketing or advertising trackers.
5Watch responses land in Submissions, where you can filter, label and export them to CSV or PDF.

Logic and conditions blueprint

Exactly how this form behaves as it is answered — 3 conditional rules ship with it.

Features advanced show logic: if “Are you currently pregnant or breastfeeding?” is Yes, the form dynamically exposes “Injector's note on proceeding”. Otherwise that question never appears.
Features advanced show logic: if “Do you have a known allergy to any botulinum toxin product?” is Yes, the form dynamically exposes “Describe the reaction”. Otherwise that question never appears.
Features advanced show logic: if “May we use before-and-after photos for marketing?” is Yes, the form dynamically exposes “Photo consent scope”. Otherwise that question never appears.
All 3 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.

About this template

A Botox consent form has two jobs: screening out the medical conditions that make treatment inadvisable, and documenting that the patient understood what was discussed before signing. This form opens with a medical history screen — pregnancy or breastfeeding, neuromuscular conditions, current medications that can interact with botulinum toxin, and any known allergy — each phrased as a direct yes-or-no question the injector reviews before proceeding. A treatment-area section records exactly where units are being placed, since consent is specific to the area treated, not to Botox in general, and a return patient's form should reflect this visit rather than a boilerplate list. The risks-discussed section lists the outcomes patients most often ask about afterward — bruising, temporary asymmetry, headache, and the possibility that results vary by individual — as a checklist the injector reviews aloud rather than a paragraph the patient skims. A photography consent question covers before-and-after images separately from the treatment consent itself, since a patient may agree to treatment without agreeing to have photos used for marketing. The form closes with the patient's signature confirming they had the chance to ask questions. It is a documentation tool for a licensed provider's own consent process, not a substitute for the clinical judgment or the provider-specific consent language your practice already relies on.

What this form asks

Every question is editable — rename it, make it optional, or delete it entirely.

Page 1 — Medical history

Patient's full namerequired
Date of birthrequired
Are you currently pregnant or breastfeeding?required
Injector's note on proceeding
Do you have any neuromuscular condition (e.g. myasthenia gravis, ALS)?required
Do you have a known allergy to any botulinum toxin product?required
Describe the reaction
Current medications, especially blood thinners or muscle relaxants

Page 2 — Treatment and consent

Areas being treated todayrequired
Risks discussed with the patientrequired
May we use before-and-after photos for marketing?required
Photo consent scope
Agreementrequired
Patient's signaturerequired
Date signedrequired

15 questions in total.

How the form changes as it's filled in

This template ships with 3 conditional rules, grouped into 3 behaviours driven by 3 questions. Everything below is already set up — edit or delete any rule once the template is in your workspace.

Driven by “Are you currently pregnant or breastfeeding?”

Reveals questions
If “Are you currently pregnant or breastfeeding?” is Yes, the form reveals “Injector's note on proceeding”.

Driven by “Do you have a known allergy to any botulinum toxin product?”

Reveals questions
If “Do you have a known allergy to any botulinum toxin product?” is Yes, the form reveals “Describe the reaction”.

Driven by “May we use before-and-after photos for marketing?”

Reveals questions
If “May we use before-and-after photos for marketing?” is Yes, the form reveals “Photo consent scope”.

Set it up step by step

1
Review the medical history before booking the injector's time
A pregnancy or allergy answer that surfaces at the chair wastes an appointment slot that a pre-visit screen would have caught.
2
List the actual areas treated, not a generic list
Consent is specific to the areas injected this visit, so tailor the checklist to what is actually happening today.
3
Talk through the risks list, don't just hand it over
The checklist works as a conversation guide for the injector, not a form the patient reads alone in the waiting room.
4
Keep photo consent separate from treatment consent
A patient can consent to treatment while declining marketing use — don't bundle the two into one signature.

Mistakes to avoid

Using one generic consent form for every visit instead of updating the treatment-area list each time.
Skipping the medication question, missing a blood thinner that changes bruising risk.
Treating photo consent as automatically included in treatment consent.

What it pairs with

Most teams don't run this form on its own. These are the forms and systems it sits next to.

What to do with the responses

File the signed consent in the patient's chart before treatment begins, and flag any medical history answer that needs a second look to the treating provider.

Works in both layouts

Browse classic templates Browse card templates

Forms that overlap this one

These pages cover the same subject ground as the botox consent form, matched on the words people actually search for.

Privacy & compliance

This form collects health information. Keep access limited to the people who need it, turn on encrypted answers for the clinical questions, and set a retention window so records don't sit in the dashboard forever.

Frequently asked questions

Does this replace my clinic's existing consent process?

No — it is a documentation template you adapt to your own provider-specific consent language and clinical protocols, not a substitute for either.

How is this different from Microblading Consent Form?

The structure is similar, but the medical history questions, treatment areas and risk list here are specific to botulinum toxin injections rather than a pigment-based cosmetic procedure.

Do returning patients need to sign every visit?

Yes — consent should reflect the areas treated and any changes in medical history for that specific visit, not a one-time signature from a prior appointment.

Can non-medical staff collect this form?

The form itself can be completed at check-in, but the risks-discussed section should be reviewed with the treating injector, not delegated to front-desk staff.

Is the Botox Consent Form template free to use?

Yes. You can preview and test Botox Consent Form on this page without an account, and take a copy into your own HelloForms workspace on the free plan. There is nothing to install and no card required to publish it.

What does the Botox Consent Form template ask for?

It asks 15 questions across 2 pages, 11 of which are required. Every question is listed in full further down this page, and each one can be renamed, reordered, made optional or deleted after you copy the template.

Can I edit the Botox Consent Form form after copying it?

Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the classic and card layouts, restyle it to match your brand, and set who gets notified on each submission.

How does the conditional logic in this consent, waivers & releases form work?

3 conditional rules ship with the template: Features advanced show logic: if “Are you currently pregnant or breastfeeding?” is Yes, the form dynamically exposes “Injector's note on proceeding”. Otherwise that question never appears. Features advanced show logic: if “Do you have a known allergy to any botulinum toxin product?” is Yes, the form dynamically exposes “Describe the reaction”. Otherwise that question never appears. Features advanced show logic: if “May we use before-and-after photos for marketing?” is Yes, the form dynamically exposes “Photo consent scope”. Otherwise that question never appears. All rules are editable in the Logic tab.

Where do responses to the Botox Consent Form form go?

Submissions land in your workspace under Submissions, where you can search, filter, label and export them to CSV or PDF. You can also email a notification to your team on every submission and send the respondent an auto-reply.

Can I embed the Botox Consent Form form on my own website?

Yes. Publish the form and paste the embed snippet into any page or share the direct link. The embedded form resizes to fit its container and loads no advertising or marketing trackers inside the iframe.

Is the signature on this form legally usable?

The template captures a drawn signature and stores it with the submission, along with the timestamp, so you keep evidence of who agreed and when. Whether that is sufficient depends on your jurisdiction and the agreement itself.

More forms teams pair with the botox consent form.

Related categories

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