Anti-Wrinkle Treatment Consultation Form Name Date of Birth Email Address Phone Number Emergency Contact: Emergency Contact Phone Number Medical History 1.Do you have any known allergies? Yes No If yes, please specify: 2.Are you currently taking any medications, including over-the-counter drugs and supplements? Yes No If yes, please specify: 3.Do you have any chronic medical conditions (e.g., diabetes, hypertension, heart disease)? Yes No If yes, please specify: 4.Have you had any previous cosmetic treatments or surgeries? Yes No If yes, please specify: 5.Do you have a history of cold sores or herpes simplex? Yes No If yes, please specify: 6.Are you pregnant or breastfeeding? Yes No If yes, please specify: 7.Do you have any history of neuromuscular disorders (e.g., myasthenia gravis, ALS)? Yes No 1.What areas are you concerned about? Forehead Crow's Feet Frown Lines Other: 2.Have you had anti-wrinkle treatments before? Yes No If yes, when was your last treatment? Consent and AgreementI confirm that the information provided above is accurate and complete to the best of my knowledge. I understand that withholding any medical information could result in complications and that the practitioner will not be held liable for any issues arising from undisclosed conditions. I have been informed about the treatment process, potential risks, and side effects, and I consent to proceed with the anti-wrinkle treatment. I Agree Client Signature Submit
