I have informed the RN of all current medications and supplements. I have also informed Aeris Medical Aesthetics of any known allergies to drugs or other substances, or of any past reactions to anesthetics.

I understand that I have the right to be informed of the procedure, any alternative options, and the risks and benefits of IV therapy. Procedures will not be performed until I have the opportunity to give my informed consent, except in the case of an emergency.

My signature below acknowledges that:

This procedure involves inserting a needle into the vein and injecting a prescribed solution.
Alternatives to IV therapy include, but are not limited to, oral supplementation.
The potential risks of IV therapy include, but are not limited to:
I. Occasionally: Discomfort, bruising, and pain at the injection site.
II. Rarely: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.
III. Extremely rarely: Severe allergic reaction, anaphylaxis, infection, cardiac arrest, and death.
Benefits of IV therapy include:
I. Injectables are not affected by stomach or intestinal absorption disturbances.
II. The total amount of infusion is available to the tissues.
III. Nutrients are forced into cells by means of a high concentration gradient.
IV. Higher doses of nutrients can be given than is possible by oral consumption.
I am aware that unforeseeable complications could occur, and I do not expect Aeris Medical Aesthetics RNs to anticipate or explain all possible complications. I rely on the RN’s to exercise judgment during the course of my treatment. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered.

I understand that I have the right to consent to or refuse any proposed treatment at any time.

My signature affirms that I have given consent to IV therapy with Aeris Medical Aesthetics. I understand that all nutrient infusions are considered investigational/experimental and are not considered standard of care.

My signature below confirms that:

• I understand the information provided on this form and consent to treatment.
• The procedure(s) set forth above have been adequately explained.
• I have received all the information and explanation I desire pertaining to the procedure.
• I authorize and consent to the procedure(s).

I understand that although good results are expected, there cannot be any guarantee or warranty, expressed or implied, that I will be completely satisfied by the outcome or that I will not require additional treatment and/or ongoing treatment to achieve the result I seek. I understand that treatments will not cure any medical conditions nor provide immunity against re-occurrence of such conditions. The treatments are temporary and very per patient with some patients experiencing shorter or longer effects. The number of treatments needed varies per patient and may be affected by the following factors including but not limited to: degree of skin irregularity; severity of volume loss; patient age; personal medical profile; basic metabolic rate; previous cosmetic procedures; history of trauma to the treated area; individual lifestyle choices; and individual patient preference. I understand that all product and service sales are final. No refunds on services or products. I have read and understand all information presented to me before signing this consent form. I have been given an opportunity to have all of my questions answered to my satisfaction. I understand the procedure and accept the risks. I agree to the terms of this agreement. Except where prohibited by law; I acknowledge and voluntarily assume the risk of injury, accident or death which may arise from the use of any skincare products or services preformed by Halo Med Spa. I agree Halo Med Spa will not be liable for death or any injury, including, without limitation, personal, bodily or mental injury, economic loss or damage to me resulting from negligence, other acts in Halo Med Spa, anyone acting on Halo Med Spa's behalf, or anyone using the services of the facilities of Halo Med Spa, to the fullest extent permitted by law. This agreement together with Halo Med Spa's post-care plan rules and regulations, constitute the entire agreement between you and us and cannot be amended, except in writing by both parties. Myself and/or any of my heirs, executors, representatives, or assignees hereby release Halo Med Spa from all claims or liabilities for death, personal injury or property loss or damages of any kind sustained while on the premises. I agree that this form and waiver is in effect for all services offered by Halo Med Spa, and will not expire unless specifically requested by either party. I understand that Halo Med Spa is a tranquil and professional environment and that any inappropriate behavior may result in termination of my services and full payment is expected. I also understand that any medical device used by the patient outside of Halo Med Spa care or failing to list or mention such medical devices could result in unexpected or unwanted results. By signing this form, I agree to the above terms and release Halo Med Spa and its employees from any liability.

 

If you have any questions or concerns please call our office at 505-433-4043

In case of emergency contact your provider.

Amanda Medina- Amanda@halomedspaabq.com or  505-717-9401

Trese Avery- Trese@halomedspaabq.com or 575-551-8202

Michelle Montoya- Michelle@halomedspaabq.com 505-464-4978

 

Medical Director: Luis Mojicar, MD