BOTOX INJECTION INFORMED CONSENT FORM


Patient’s Name:
File No.:
DOB:
Mobile Number:
Visit Date:
Registration Time:
Doctor Name:


Patient Name & Signature :   

Doctor/Therapist Name & Signature :   

Witness Name & Signature :     

Parent or Gaurdian Name (if patient is minor) :

Date :

Consent to be photographed and published

I, , consent to be photographed and published on by while .

I further authorize that the photographs may be published for any purpose and in any form.

Patient Name & Signature :