KARINE LAUZON RN CLINICS

BOTOX^® & DERMAL FILLER

INTAKE, CONSENT & TREATMENT RECORD

Ottawa · Kanata · Carleton Place

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1Client Information

Full Name *

Date of Birth *

Age

Occupation

Phone *

Email *

Address

City

Province

Postal Code

Emergency Contact Name

Relationship

Emergency Phone

2Medical History

Please answer Yes or No for each question.

Are you pregnant, planning pregnancy or breastfeeding?

Do you have a neurological disorder (e.g., Myasthenia Gravis, ALS)?

Do you have an autoimmune disorder?

Do you have a bleeding disorder?

Are you currently taking blood thinners or anticoagulants?

Do you have high blood pressure or cardiovascular disease?

Do you have a history of keloid or hypertrophic scarring?

Do you have a history of cold sores (HSV)?

Do you have any allergies (medications, latex, lidocaine, etc.)?

Do you have any active infection, acne, rash or skin condition in the treatment area?

Have you had any facial surgery?

Do you have difficulty swallowing or breathing?

Any other medical conditions we should know about?

Allergies — please list

Other conditions — please list

3Current Medications & Supplements

Please list all prescription medications, over-the-counter medications, supplements, vitamins and herbal products (include dosage if known).

4Previous Treatment History

Botox® / Neuromodulator

Have you had this before?

Dermal Filler

Have you had this before?

5Treatment Today

Please select the treatment(s) you are having today:

Botox® / NeuromodulatorDermal FillerBoth

Areas to be treated (check all that apply):

Specific concerns or notes about treatment areas

Risks & Possible Side Effects:

Botox®: temporary redness, swelling, bruising, headache, eyelid or brow drooping (ptosis), asymmetry, dry eyes, flu-like symptoms, or allergic reaction.

Dermal Filler: temporary redness, swelling, bruising, tenderness, lumps/bumps, asymmetry, infection, vascular occlusion, skin necrosis, scarring, blindness (rare), or allergic reaction.

Post-Treatment Guidelines:

Avoid lying down for 4 hours
Avoid strenuous exercise for 24 hours
Avoid alcohol, saunas and hot yoga for 24 hours
Do not massage or apply pressure to treated areas
Use arnica or cold compresses for bruising (if appropriate)
Contact the clinic if you experience any unusual symptoms or concerns
Follow-up appointment at 14 days if needed

Consent & Acknowledgement

Required: I confirm I have disclosed my full medical history. I understand the nature, risks and benefits of the treatment. I have had the opportunity to ask questions. I consent to treatment with Botox® and/or dermal filler as selected. I understand results vary and no guarantees have been made.Required: I consent to emergency treatment, including the use of hyaluronidase if required for filler complications (vascular occlusion, blindness or tissue necrosis are rare but serious risks).Required: Financial Policy: All services are professional in nature and all sales are final. Payments are due in full at the time of service. No refunds. Touch-ups (if needed) are performed within 14 days at the discretion of the injector.

Photo / Media Consent

I consent to before/after photographs for my medical recordsI consent to the use of my photos for marketing purposes (identity protected)I do not consent to the use of my photos

Signature

Sign with your finger (touch) or mouse (desktop):

Signed Date

Once submitted, this form is kept on permanent file. Karine and her team will see it on your client record. You'll receive a confirmation and can download a copy any time.

WE APPRECIATE YOUR TRUST · KARINE LAUZON RN CLINICS

BOTOX® & DERMAL FILLER