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    How to build a Botox treatment form (template included)

    How to build a Botox treatment form (template included)

    Many clinics offer Botox. It’s one of the most popular treatments out there and millions love it as it helps people eliminate their frown lines, crow’s feet, etc.

    But are you confident your Botox treatment forms is comprehensive enough? 

    A comprehensive Botox treatment form is vital for both parties, the client and the practitioner. It ensures the client is fully informed and understands the treatment they will undergo, including the potential risks and benefits, and it also safeguards 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 as comprehensive as they need to be?

    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 included in 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: This is essential 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’re suitable candidates for Botox injections.

    This information helps you identify potential risks, contraindications, and any precautions you should take. This section 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’re taking: You must know about medications 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, where clients can access their information via a secure portal.

    They’re highly effective not just for gathering patient data, but they’re also actually 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, the benefits of it, and, of course, the risks and potential side effects. 

    Also, keep in mind that the consent is: 

    • In the language the client speaks/understands
    • Doesn’t read like a medical textbook. It needs to be explained in layman’s terms, in as simple as possible a way 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 to match your client’s aesthetic goals, clearly identifying the areas they want to be treated. 

    A client will also generally book an injectable treatment based on the area, such as one area, two areas, three areas, and so on. But 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.

    Of course, not everything the client wants to be done should be doneYou must use your professional judgement to decide on the right amount to prevent complications or poor results, such as drooping eyelids or asymmetry.

    5. Pre-treatment guidelines 📑

    To ensure safety and optimal results, you must inform clients how to prepare before their Botox treatment. 

    Clear and concise written communication is the best format – much better than communicating it verbally! 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 a link to the key prep points, keeping it brief and easy to digest.

    6. Post-treatment care instructions💆‍♀️

    As any good practitioner knows, you’re not done treating the client after you’re done injecting Botox. That’s just the start of the treatment journey.

    You must also provide clients with detailed post-care instructions, and again this is better to be sent in a written format so clients can refer to it later. This will guide clients on what to do after the procedure and how to get the best results. 

    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 potentially lead to bruising. 
    • 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
    • Build trust: Putting the effort into creating clear aftercare instructions show that your clinic is thorough, caring, and invested in the client’s long-term care and satisfaction – not just getting their money. 

    7. Photography consent 📸

    Most clients don’t want pictures taken of them without their permission. 

    That’s why practitioners should always obtain permission from their clients before taking before-and-after photos. You should clearly explain to clients why you need these images and how they will be used i.e. to track their progress. 

    Being transparent about this and making sure you get that consent fosters the idea of professionalism and respect for the client’s privacy. 

    Additionally, before-and-after photos can support your marketing efforts – like these creative filler promotion ideas – by showcasing your results. However, you must always get written marketing consent to use photos in this way.

    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’re 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’s 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.
    • 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 in the US meet the Health Insurance Portability and Accountability requirements.

    It ensures that protected 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 even 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 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. They should also be up to date with any medication your client is taking or has started taking recently, which could impact results.

    Maintaining up-to-date medical records also help protect you against legal and financial issues 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 have a clear understanding of your client’s medical history and aesthetic goals, while minimizing the risks. 

    In other words, they help you manage and and set 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 if you’re 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’re crucial for ensuring safe and effective treatments. 

    These questions must be specific and identify if the patient has perhaps an allergy (such as an allergy to latex or certain preservatives found in Botox), or they have a pre-existing condition, such as neuromuscular disorders, that may make them at higher risk for complications from Botox. 

    Building it into every appointment also gives clients a chance to review and update their medical information, in case their circumstances change.

    Botox treatment form template to use

    Automate your med spa’s treatment forms with Pabau

    Using comprehensive Botox treatment forms as part of the patient journey key to delivering safe, effective, and personalized treatments. 

    These forms also help you assess patient suitability, flag potential risks, and tailor the treatment plan to each patient’s specific needs, which can contribute to an enhanced client experience and even better overall med spa sales.

    With Pabau, the all-in-one practice management system, you can automate your med spa’s treatment forms and trigger them to be sent out before each appointment, and handle them digitally. No more paper!  

    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

    ✅Reduce appointment times so you operate more efficiently!

    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!

    What you should do now

    1. Schedule a Demo to see how Pabau can help your team.
    2. Read more clinic management articles in our blog.
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