Attendee Form

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ATTENDEE
FORM

Injection Consent & Release Form

This form must be completed before all injection bookings.

First name*

Date of Birth

Phone*

Email*

Do you have any allergies (including to medications)?*

Yes

If yes, please list:

Current medications (prescription, OTC, herbal):*

Do you have any of the following conditions? (Check all that apply)*

Neuromuscular disorders (e.g., ALS, myasthenia gravis)

History of facial surgery or implants

Skin infections or active cold sores

Bleeding disorders or on blood thinners

Autoimmune diseases

Cancer

Diabetes

High blood pressure

Hepatitis or HIV/AIDS

Thyroid issues

Any active infection

Other

Other medical conditions:*

Have you had Botox or other neuromodulators before?*

Yes

If yes, when and what areas:

Other treatments (fillers, lasers, etc.):

What areas would you like treated? (e.g., frown lines, crow's feet, forehead):

***Risks and Side Effects: Include but not limited to: pain at injection site, bruising, swelling, redness, headache, drooping eyelid or eyebrow (ptosis), asymmetry, infection, allergic reaction, dry eyes, double vision, difficulty swallowing or breathing (rare), spread of toxin effects (rare but serious). No guarantees on results or duration.***

I have been informed of the procedure, benefits, risks, alternatives, and have had all questions answered. I consent to treatment and release Cactus Mobile Wellness LLC and its providers from liability for any complications. I agree to follow post-treatment instructions. Photographs may be taken for medical records.

I acknowledge that I have read the refund policy.

I acknowledge that I have read the post-treatment-instructions.

I acknowledge that I have read the patient acknowledgement form

Date*

Printed Name*

Patient Signature (type full name)*

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Upload your before picture of the area you want treated