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Many clinics offer Botox. It’s one of the most popular treatments out there. Millions love this treatment as it helps people eliminate their frown lines, crow’s feet, etc.
But do you always give Botox treatment forms?
A comprehensive Botox treatment form is vital for both parties, the client and the practitioner. It ensures the client is informed and understands the treatment they will undergo, including potential risks and benefits, while safeguarding the practitioner from misunderstandings and legal claims.
This blog explains everything that should be included in a Botox treatment form and provides a free template you can use today.
What should be included on a Botox treatment form?
There are a lot of templates for consent forms that you can find online. But the question is, are all of them good?
Let’s look at the elements that a good treatment form should include.
1. Client information👤
Basic client details are obligatory, and they should be the first section of the Botox treatment form. This information includes:
- Patient name: Ensure the records match the patient
- Date of birth: Assess age-specific health risks and tailor therapy accordingly
- Gender: It might help you understand specific health requirements
- Contact information: Collect accurate phone number, home address and email for appointment reminders and post-care instructions
- Emergency contact: In case of an urgent issue, such as an adverse reaction during the Botox treatment session
2. Medical history📖
Gathering your patient’s medical history helps you assess their overall health condition and determine whether they are suitable candidates for Botox injections.
This information helps you identify potential risks, contraindications, and any precautions you should take, and it should include:
- Any allergic reactions: Specifically medications or ingredients like latex in Botox vials, as some allergies can be severe and life-threatening.
- Medications they are taking: To prevent adverse contraindications with the Botox treatment.
- Overall past medical history: A patient’s history of muscle or nerve conditions, along with prior facial surgeries, laser treatments, or scarring, can significantly influence their sensitivity to Botox and determine the safety and effectiveness of injection sites.
Speaking of collecting client’s medical history, it’s good knowing about the benefits of patients portals.
They are highly effective not just for gathering patient data, they are also preferred by clients. In fact, 78% of patients favor secure online methods to access their medical histories and 59% of Gen Y patients would switch doctors for one that offers improved online access.
3. Consent to treatment🤝
Informed consent before treatment is equally as important as the treatment itself. It protects both you and the person who will receive the treatment.
To prevent misunderstandings and lapses in communication, you must ensure your patients understand what is about to happen during the cosmetic procedure every step of the way, the benefits of it, and, of course, the chances of less-than-optimal outcomes.
Also, keep in mind that the consent is
- In the language they speak/understand
- Doesn’t read like a medical textbook, and it is as simple as possible for them to understand
4. Treatment areas and dosage💉
One thing is sure: each client has unique facial anatomy and aesthetic goals. This means you’ll have to customize the treatment plan, clearly identifying the areas they want to be treated.
Also, you should be clear about the Botox dosage you’ll be administering in each area, for example, up to 20 units for the forehead, up to 20 for the 11s (Glaberall lines), or 4 to 6 for a lip flip.
This is VERY important because not everything the client wants should be done. That’s just not right. You need to inject the right amount to prevent complications such as drooping eyelids or asymmetry in whatever area you’ll be treating.
5. Pre-treatment guidelines 📑
To ensure safety and optimal results, you must inform clients how to prep before their Botox treatment.
Clear and concise written communication is the best format, so emailing them a couple of days before their appointment, outlining what they should do and what not to do is essential. What you can also do is send them a quick text message a day or two before the treatment with the key prep points, keeping it brief and easy to digest.
Or, if a client books online, you can provide a small flyer or card with the pre-treatment tips at the time of scheduling.
6. Post-treatment care instructions💆♀️
After you are done injecting Botox, you are still not completely done treating the client.
You must also provide them with detailed post-care instructions. This is an essential step cut for conciseness to guide clients on what to do after the procedure and how to make it last as long as possible.
Providing them with proper post-treatment aftercare instructions helps clients
- Minimize side effects such as bruising or swelling: Advise them to avoid alcohol and sun exposure as it can speed up the recovery process
- Feel more satisfied: The more clients know how to properly take care of their skin post-treatment, the more likely they’ll be satisfied with the outcome
- Aftercare instructions help clients build trust and offer a sense of professionalism: They show that your clinic is thorough, caring, and invested in the client’s long-term satisfaction
7. Photography consent 📸
Most clients don’t want pictures taken of them without their permission. Logically, practitioners should always obtain permission from their clients before taking before-and-after photos.
You should explain to clients why you need these images and what’s their purpose in the whole process.
Being transparent about the need for these images fosters the idea of professionalism and respect for the client’s autonomy, making the process much less awkward. Additionally, before-and-after photos can support creative filler promotion ideas by showcasing transformative results.
8. Liability waiver📝
The thing with Botox is that when the procedure goes wrong, it can have catastrophic consequences for both the client and you. That’s exactly why you need a liability waiver as your shield. A liability waiver differs from an informed consent, though they are often used together for procedures like Botox.
A liability waiver is a legal document that protects the practitioner and the clinic from being liable for certain outcomes of the treatment. Here is how it works:
- Waiver of liability: Once signed, the client agrees not to hold the practitioner responsible for complications or unsatisfactory outcomes of the procedure they had.
- Legal protection: It legally protects the practitioner and reduces the chances of a client suing for outcomes that were clearly outlined as potential risks.
💡Good to know: The limitation of the liability waiver is that it doesn’t protect against negligence or malpractice. If the practitioner makes an error due to carelessness, the waiver may not hold up in court!
9. Acknowledgement of understanding 👍
The informed consent is an acknowledgment that confirms the client has read, understood, and accepted all instructions related to the Botox treatment they’ll have. It ensures the client is aware of:
- The procedure: They fully understand how the Botox will be administered to them, including the pre and post-treatment care.
- The risks: They acknowledge any possible side effects or complications that may arise after the treatment, such as mild and temporary headache, bruising and swelling for a few days, dry eyes, and rarely, flu-like symptoms or allergic reactions like itching or rash.
10. Date and signature✍️
After reviewing and explaining the Botox consent form, both the client and practitioner sign it to confirm their understanding of the risks and instructions. Also, the patient’s signature means that the patient is ready to proceed.
Remember to date the form accurately, ensuring it aligns with the timing of the treatment itself.
Legal and ethical considerations for your Botox treatment form
When creating a Botox treatment form, it’s crucial to consider legal and ethical factors while ensuring it covers the essential elements needed for med spa compliance. This is important to protect both the patient and your company.
HIPAA compliance
HIPAA compliance refers to how healthcare organizations meet the Health Insurance Portability and Accountability requirements.
It ensures that private health information (PHI), including medical records and other sensitive patient health data is handled securely and kept confidential.
Non-compliance with HIPAA rules can lead to penalties ranging from $100 up $1,5 million, or imprisonment.
Informed consent
Getting consent alone isn’t enough. It has to be what’s called ‘informed consent.’ That means the client has to be well-informed of all possible risks and complications of the treatment, no matter how small or uncomfortable.
Obtaining an informed treatment consent is crucial for several other reasons:
- Protecting you from legal issues
- Managing client’s expectations
- Promoting patient safety
- Fostering professionalism and credibility of your business
Record keeping
Your clients’ treatment records must always be accurate and secure. They should document all previous procedures, dosages, and potential outcomes to ensure that future treatments align with the patient’s history and to prevent adverse reactions.
Also, maintaining up-to-date records ensures legal and financial compliance and protection in case of a dispute or malpractice claim.
Questions to ask on the Botox treatment form
Before administering Botox, you must know the right questions to ask your clients. The answers you’ll gather from those will help you access your client’s medical history and aesthetic goals while minimizing the risks and setting clear expectations.
Patient information
Proper record-keeping and effective communication with your client starts with gathering the basics, such as:
- Full name and date of birth
- Home address, phone number and email
- Emergency contact, relationship and phone number in case of any complications
Botox treatment informational questions
Double-checking never hurt nobody. Even though you are sure that everything was already mentioned to your client and they fully understand what the procedure entails, still, you can ask other informational questions such as:
- Can you confirm what areas of the face we’ll treat today?
- What outcomes do you expect from this treatment, and how do you envision your appearance post-treatment
- Do you have any questions about the treatment or the aftercare instructions that we can discuss before we begin?
Medical history questions
Medical history questions must be included in every Botox consent form. They are crucial for ensuring safe and effective treatments.
These questions must be specific and identify if the patient has perhaps an allergy to latex or certain preservatives found in Botox or has a pre-existing condition, such as neuromuscular disorders, that may be at higher risk for complications from Botox.
Botox treatment form template to use
Automate your med spa’s treatment forms with Pabau
Botox treatment forms are key to delivering safe, effective and personalized treatments. They also help you assess patient suitability, flag potential risks, and tailor the treatment plan to each patient’s specific needs, contributing to better overall med spa sales.
With Pabau, the all-in-one practice management system, you can automate your med spa’s treatment forms and handle them digitally. Here’s how Pabau makes that a breeze:
✅ Sends intake forms and pre and post-care instructions automatically
✅ Flags any allergies and contraindications
✅ Pulls patient data directly into the client profile
✅Manages patient records from anywhere, anytime
It’s time you level up your Botox treatment forms and experience the difference Pabau can make for your med spa. Book a demo now and see for yourself!
