Botox Patient Authorization Consent Form

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The Botox consent form is a document that should be provided to the Botox patient prior to the performance of the operation. It provides confirmation with complete certainty that the patient is fully aware of the risk involved, the purpose of the treatment, and the impermanence of a single treatment. The patient should initial next to each disclaimer to signify that they understand and consent. Once the patient has completed the form, they should sign it and obtain the signature of a witness.

How to Write

Step 1 – Download in Adobe PDF (.pdf).


Step 2 – The patient’s name and date can be submitted at the top. The patient should then review the information in the “To the patient:” section.

Step 3 – Enter your name again here and be sure to review the information in this paragraph as well.

Step 4 – This section explains the result of the treatment and how the treatment is performed. Initial if understood.

Step 5 – This paragraph explains the side effects of the treatment. Initial when ready.

Step 6 – The results of Botox are temporary and numerous sessions may be required. Again, initial when ready.

Step 7 – This is the disclaimer that ensures that the consent form has been fully understood and that any questions have been answered. Initial giving your full consent for treatment.

Step 8 – Your signature and that of a witness must be submitted along with the date of signing once the document has been printed out.