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Medical History
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Is the PT 18 years of age or older?
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Is Patients parent or legal guardian present
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Does patient have any Medical Conditions?
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If yes, please list:
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Does patient take any medications?
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If yes, please list:
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Does patient have any allergies?
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If yes, please list:
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Is patient pregnant or breastfeeding?
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Notes:
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Botox + Dysport
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1. History of Botox, Xeomin or Dyport treatment in the past?
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IF YES: Which products and when?
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If less than 3 months:
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Patient verbalized understanding to this warning.
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2. Any adverse reactions to the product?
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If YES, was the adverse reaction systemic or allergic in nature?
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3. History of ALS, Lambert-Eaton Syndrome or myasthenia gravis?
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4. Skin Infection or inflammation in treatment area?
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5. Allergic to cow's milk protein (not lactose, which is the sugar in cow's milk)?
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6. Heart or breathing problems?
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IF YES: What heart or lung condition does the patient have?
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IF YES: Is the condition mild and stable?
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7. Difficulty swallowing?
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8. Bleeding or clotting disorder?
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IF YES: Is the condition mild and stable?
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6. Current use of anticoagulant medication?
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Patient verbalized understanding to this warning
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7. Permanent implants (other than dental) in treatment area?
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IF YES:
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Nurse Provider and patient verbalized understanding to this warning.
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Cleared for Botox/Dysport
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Dermal Fillers
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1. History of hyaluronic acid filler treatment in the past?
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IF YES: What products and when?
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2. Any adverse reactions to the product?
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IF YES: Please describe:
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Was the adverse reaction systemic or allergic in nature?
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3. Skin Infection or inflammation in treatment area?
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4. History of anaphylaxis or severe allergic reactions to any substance?
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5. Bleeding or clotting disorder?
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IF YES: Is the condition mild and stable?
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6. Current use of anticoagulant medication?
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Patient verbalized understanding to this warning
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7. Permanent implants (other than dental) in treatment area?
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IF YES:
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Nurse Provider and patient verbalized understanding to this warning.
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8. History of Keloid or hypertonic scars?
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IF YES:
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Nurse Provider and patient verbalized understanding to this warning.
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9. Immune suppression or immune deficiency to medication or disease process?
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IF YES:
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Nurse Provider and patient verbalized understanding to this warning.
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10. History of herpes infection?
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IF YES: Herpes 1/2, current outbreak in treatment area?
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Patient verbalized understanding to this warning
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Cleared for Dermal Fillers
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Additional Comments
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Standing Orders:
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Discussion with Patient
• • •
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Signature of Patient
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I approve this patient for the requested procedure(s) as noted in this document
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Name/Signature of NP/PA/MD
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