Consent Form Information

Here is the MyMediSpa Consent Form General Information

Derma Science Screening Form for BOTOX® Treatment
*Patient Name:_________________________________
*Mailing Address:_______________________________
*City, State, Zip:________________________________
*Phone Number:________________________________
*Date of Birth: (mm-dd-yyyy)_____________________
*Email Address:________________________________

Medical History:
Do you or have you ever had any of the following?
Rheumatic Fever
Heart Trouble
Heart Murmurs
Heart Palpitations
Irregular Heart Beat
Previous Angiogram, Heart Attack, Heart Disease, Chest Pains or Heart Surgery
Shortness of Breath
Swelling of Ankles
High Blood Pressure
Herpes "Fever Blister "
Anemia
Chronic Lung Problems
Diabetes
Cancer
Kidney Problems
Eye Diseases
Hepatitis
Thyroid Problem
Asthma
Blood Disorders
Skin Disorders
Trouble with dryness, soreness, burning, itching, or excessive tearing of eyes
Any other serious illness
Hospitalizations and/or previous surgery: Please list with dates:
Allergies: Are you allergic to or have you ever had a reaction to any medication, drug or local anesthetic? Please list:
Medications: Are you now or have you ever taken any medications on a regular basis (aspirin, birth control pills, vitamins included)? Please list:
Are you now or have you ever taken a prescription or over the counter medication for allergies, stuffiness, difficulty breathing, sinuses or other nasal problems? Please list:
Bleeding/Scarring/Anesthesia:
Do you or any member of your family have difficulty with prolonged bleeding when cut?
Do you or a member of your family bruise easily?
Do you have a problem with excessive scarring or have you ever formed a keloid after being cut?
Have you or any member of your family ever had a problem with BOTOX® injections?
Personal History:
Is your general health good?
Have you ever had psychiatric problems, a nervous breakdown or been under the care of a psychiatrist?
Do you smoke?
Do any diseases run in your family?
Do you have any questions or concerns?
Do you have any diseases that affect your nerves and muscles?
Are you pregnant, planning to become pregnant soon, or breastfeeding?
Are you taking antibiotics used to treat infections, such as gentamicin, tobramycin, clindamycin, and lincomycin?
Are you taking medicines used to treat heart rhythm problems, such as quinidine?
Are you taking medicines used to treat different conditions, such as myasthenia gravis or Alzheimer’s disease?

As with all prescription medicines, you should also notify your doctor if you are taking any over-the-counter medicines or herbal products
Goals:
Are you interested in improvement in wrinkles between the eyebrows, the glabellar or frown lines?
Are you interested in improvement in horizontal wrinkles on the forehead?
Are you interested in improvement in crows feet wrinkles at the corners of the eyes?

NOTE: All fields of this form are required.

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