Templates · Free template · Neurotoxin

Botox Consent Form Template

A printable neurotoxin consent form for Canadian med spas and injectors, with the sections a college reviewer or insurer expects to see: the specific product, the areas and units, risks and contraindications, off-label disclosure, and a separate photo consent.

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Last reviewed September 2026 · Not legal advice

Part of the Botox and neurotoxin treatment guide →

What a neurotoxin consent form has to cover

A good consent form records a conversation rather than replacing one. The patient should have had the treatment, the alternatives, the likely result, and the realistic risks explained by the person injecting, with time to ask questions. The form is the evidence that this happened and what was said.

For neurotoxin specifically, that means naming the product brand rather than writing "Botox" as a generic term, since brands are not interchangeable unit for unit. It means recording the areas treated and the planned units, because consent to treat the forehead is not consent to treat the masseters. And it means stating plainly that the effect is temporary, usually lasting around three to four months, so the patient knows a return visit is part of the plan.

Risks and contraindications to list

Common, usually short-lived effects include pain, redness, swelling, or bruising at the injection sites, headache, and temporary asymmetry. Less common effects include drooping of the eyelid or brow, which can last several weeks. The product monographs also carry a warning about distant spread of toxin effect, which can cause difficulty swallowing, speaking, or breathing; it is rare at cosmetic doses, but patients should know to seek care immediately if it happens.

Screen for pregnancy and breastfeeding, neuromuscular disorders such as myasthenia gravis or Lambert-Eaton syndrome, known allergy to any ingredient in the product, infection at the injection site, and medications that interact, including aminoglycoside antibiotics and other botulinum toxin treatments in the preceding months. Your prescriber or medical director should confirm the final list for your clinic.

Canadian specifics worth building in

In most provinces neurotoxin is a prescription drug and injection is a regulated activity carried out by, or under the direction of, a physician or nurse practitioner. The form therefore has a line for the assessing or ordering prescriber as well as the injector. Rules vary by province and profession, so confirm the requirement with your regulatory college.

Several common cosmetic areas are outside the approved indications on the product monograph. Many clinics add an off-label disclosure so the patient acknowledges this in writing. Keep photo consent separate from treatment consent, and marketing photo use separate again. Patients must be able to refuse marketing use without that affecting their treatment, and under Canadian privacy law they can withdraw consent later.

Clinic name · address · phone

Consent for Botulinum Toxin (Neurotoxin) Treatment

Patient details

Full name

Date of birth

Phone

Treatment plan

Completed by the injector before the patient signs.

Product (brand)

Lot number and expiry

Treatment areas and planned units

Assessing / ordering prescriber

Injector

Health screening

Are you pregnant, trying to conceive, or breastfeeding? Yes No

Do you have a neuromuscular condition (e.g. myasthenia gravis, Lambert-Eaton syndrome, ALS)? Yes No

Have you had an allergic reaction to a botulinum toxin product or any of its ingredients? Yes No

Do you have an infection, cold sore, or skin condition in the treatment area? Yes No

Have you had any botulinum toxin treatment in the last 3 months? Yes NoIf yes, details

Are you taking antibiotics, blood thinners, or any other medication? Yes NoIf yes, details

Do you have an upcoming event, dental work, or surgery in the next two weeks? Yes NoIf yes, details

Acknowledgements

Please initial each statement.

InitialsThe treatment, expected results, alternatives (including no treatment), and costs have been explained to me, and I have had the chance to ask questions.

InitialsI understand the effect is temporary, typically lasting around three to four months, and that results vary between people and treatments.

InitialsI understand the common risks (pain, bruising, swelling, headache, asymmetry), less common risks (eyelid or brow drooping), and rare serious risks (spread of toxin effect causing difficulty swallowing, speaking, or breathing), and I will seek medical care immediately if these occur.

InitialsI understand that some treatment areas may be outside the product's approved indications (off-label), and this has been explained to me.

InitialsI have disclosed my complete medical history and medications, and I will tell the clinic if anything changes.

InitialsI have received aftercare instructions and understand them.

Photographs

Clinical photos are part of your record. Marketing use is optional and does not affect your treatment.

I consent to:

Clinical photographs for my record
Use of photos with my face obscured for education or marketing
Use of identifiable photos for marketing
None of the above

Signatures

Client / patient signature

Date

Practitioner name and signature

Date

Template from zdrovia.ca/templates/botox-consent-form/ · Review with your medical director, regulatory college guidance, and insurer before use.

Send this form before the appointment instead of printing it

Zdrovia's form builder turns this template into a digital form your clients sign on their own phone. The signed copy files into their chart with the exact version they saw, and photo consent stays separate from treatment consent. It's free for solo practitioners, with data stored in Canada.

Start free, no card required See how digital forms work →

See how Zdrovia is set up for med spas.

Frequently asked questions

Is this Botox consent form legally valid in Canada?

It is a starting template, not legal advice. Consent in Canada is valid when the patient is informed, capable, and agreeing voluntarily, and the form is evidence of that discussion rather than a substitute for it. Have your medical director, regulatory college guidance, and malpractice insurer review the wording before you use it.

Do I need a new consent form at every visit?

Most clinics take full consent at the first treatment and a shorter reconfirmation at each later visit, with a new full form whenever the product, the treatment areas, or the patient's health history changes. Check your college's expectations.

Should photo consent be on a separate form?

It should at least be a separate, optional choice. Consent to clinical photos and consent to marketing use are different permissions. Many clinics use a dedicated photo consent form so that marketing use can be withdrawn without touching the treatment record.

Can patients sign this digitally?

Yes. E-signatures are widely used for consent in Canada. Keep a record of the exact form version the patient signed, when they signed it, and how they were identified. Zdrovia does this automatically when you send the form before the appointment.

This template is a starting point for discussion with your team and advisors, not legal or medical advice. Requirements vary by province and profession. Have your medical director, your regulatory college's guidance, and your malpractice insurer confirm the wording before you use it with patients.