Therapeutic Botox Model Application

Contact Information

Price: (Plus applicable local taxes) $4.50/unit of Botox *Prices are subject to change without prior notice

Name*

First Last

Phone*

Email*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Treatment Information

What are you interested in treating?*

Select All
Forehead and Upper Face (between eyebrows)
TMJ Pain (jaw pain)
Bruxism and Grinding
Masseter Reduction

*(you may select more than one)

Have you had any Botox treatments within the last 3 months?*

Yes
No

If yes, which areas did you receive treatment for?

Are you looking to correct a previous treatment?*

Yes
No

Have you had any head/neck surgeries?*

Yes
No

Do you have any existing health conditions?*

Are you pregnant or breastfeeding?*

Yes
No

Do you have any allergies?*

Yes
No

Are you taking any of these medications/ vitamins/supplements?*

• Aspirin or any blood thinner • (if the patient is on blood thinner because of any heart conditions SHOULD NOT be advised to stop the medication) • Ibuprofen, Excedrin, Motrin, ginkgo biloba, ginseng, flax oil, cod liver oil, fish oil, vitamin A, vitamin E and other essential fatty acids. • Avoid drinking alcohol a day before your treatment

Yes
No

Have you been a cosmetic model for the CBAM before?*

Yes
No

Select an Appointment Time

Select an estimated treatment date:*

How did you hear about us?*

Facebook
Google Ad
Instagram
Friend/family referral
Expo
Special event
Other

If other, please explain:

STUDENT REFERRALS: Who referred you?

Comments

Consent*

I have read and agree to the cosmetic model terms and conditions

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Master Injectables Program - Practical

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Board Certified Package (For MDs, PAs, NPs)

CAMP Certified Package (For Nurses)

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PDO Thread Master Course - Practical

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Instalift Thread Master Course

Other Courses (Foundational)

PRP Certificate Course - Practical

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Sclerotherapy Certificate Course - Online

Cosmetic Dermatology Certificate Course - Virtual Interactive

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Microneedling Certificate Course

Chemical Peel Certificate Course

Other Courses (Advanced)

Non-Surgical Rhinoplasty Certificate Course

Facial Cadaver Anatomy Lab

Lip Beauty Master Course

Diploma in Non-Surgical Cosmetic Gynecology

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CAMP Certified Package (For Nurses)

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Course Packages in Qc

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