Confidential Plasma Lift Intake Supplement

Welcome! This intake form is a supplement to the Confidential Skincare Intake Form. Both forms contain important information for safe consideration of your interest in the Hyaluron Treatment! If you are a longtime Spa Aeon skincare client but are new to Hyaluron, please fill out a fresh copy of the regular Confidential Skincare Intake Form so we can properly plan for your home skincare use before and after this treatment.

Here you will find many sensitive but important questions, so please fill it out privately, fully, and at a time when you have all of your skincare products, medications, and supplements at hand, and be sure to keep scrolling until you have answered everything, signed, and clicked Submit. The health and lifestyle topics addressed herein ALL have the potential for affecting your skin or causing interactions with aspects of your treatment at Spa Aeon... if they didn't, they would not be included.

Your Health Intake and Treatment Notes are held in the strictest confidence.

Full Name *

First Name Last Name

E-mail *

Phone Number *

Area Code Phone Number

What would you like to achieve from your Hyaluron Treatment?

Please take your Before Photo Now

Please check any of the following that you have had in the past 6 months: *

Botox Filler injections Cosmetic Surgery Laser treatments Chemical peeling Cryotherapy procedures None of the above Radio Frequency or Ultrasound tightening

If you checked any of the cosmetic procedures above, please list the date(s) of administration and any complications you experienced:

List all current medications here: *

List all current supplements here: *

List all known allergies, ESPECIALLY allergies to any medications and/or numbing agents such as lidocaine, prilocaine, benzocaine, tetracaine, or epinephrine *

Do you consent to the treatment parameters as follows: *

Hyaluron treatment serums are transparent, biodegradable hyaluronic acid gel of non-animal origin; the effects of the treatment last for an average of 6-12 months and depend on the type of skin, the infusion site, the infused amount of the preparation, but also on my lifestyle factors. Treatment price does not include any subsequent touch-ups, and follow-up appointments are payable according to the price list or agreed upon pricing with the administering technician I acknowledge I have received detailed information about the course of the Hyaluron procedure, the mode of operation, and the indications and contraindications for the treatment I understand that the immediate post-procedure results will change, often to a considerable extent (it's typical for the added thickness to reduce by 50% and the added wideness to reduce by 30% of the result seen right after treatment), and that it's typical for optimal results to be achieved in more than one visit I've been informed of the usage, indications, contraindications, and possible side effects, and have answered with honesty all the questions I have been asked regarding my medical and aesthetic (plastic surgery) history. I have had the opportunity to ask any questions and have received a satisfactory answer to all of them I understand that there is usually some discomfort in the process of the Hyaluron treatment, and have discussed the relative merits of topical numbing options with the administering technician as part of my treatment plan I've been informed and accept the risk that after an infusion with a preparation of hyaluronic acid, the following side effect may occur: redness, swelling, erythema, bruising, pinching, or pain when touched (up to a week after the procedure). It's possible that at the application site, a thickening of the skin or possible papule may form I've been informed that the persistence of inflammatory reactions for more than a week or the occurence of any other side effects should be immediately reported so that the administering technician can address them properly. It's possible that side effects may require treatment for up to several months I've been informed that in rare cases, as with any skin filling procedure (permanent, semi permanent or non-permanent) there is always a theoretical risk of severe hypersensitivity, Tyndall effect, skin necroses, blood vessel occlusion, infection, and risk of damage to body parts due to restricted blood flow which would require medical attention, and I accept this risk

Do any of the following Hyaluron treatment contraindications apply to you currently? Be sure to read closely and answer truthfully: *

acute or chrinic skin diseases in the area where the procedure is to be performed an active infection or inflammation in the area where the procedure is to be performed (for example: cold sore, current acne breakout) predisposition to form hypertrophic scars and/or keloids current use of NSAIDs (non-steroidal anti-inflammatory drugs like aspirin, ibuprofen, naproxin, or others in this category) blood coagulation or clotting disorders pregnancy or lactation active autoimmune disorder or reactions None of the above

Do you agree to the following post-treatment recommendations? Check all: *

immediately after the procedure, avoid touching, exerting point pressure, or applying any preparations to the treated area for the next 8 hours to prevent infection or migration of the filler from the site of introduction for 12 hours after the treatment, intense exercise should be avoided to reduce the risk of bruising if necessary and if you are predisposed to herpetic lesions, anti-herpetic prophylaxis should be used in advance and immediately following treatment on the first day, avoid hot drinks and heating the mouth area (in the case of Hyaluron treatment in the mouth area) for 2 weeks after the procedure, extreme temperatures (e.g. sauna) and tanning should be avoided, as well as UV radiation avoid smoking cigarettes for a minimum of 6 hours following the procedure in the initial post-procedure period, do not exert excessive pressure on the treated area for 1-2 weeks following procedure standard skin care should be resumed 24 hours after the procedure

Photography Requirement: *

I understand that before and after photos must be taken, and that these photos remain the property of Aeon Aesthetics, LLC

Marketing Use of Photograpy:

I further optionally consent for my before and after photos to be shared for marketing purposes with my identity obscured I further optionally consent for my before and after photos to be shared for marketing purposes in their entirety

I understand, have read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritations to the skin and/or in rare circumstances, medical complications from the treatments received. I am aware that it is my responsibility to inform the Hyaluron Technician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Spa Aeon, Aeon Aesthetics, LLC, Christine Giustra, and our employees, contractors, and agents from liability and assume full responsibility thereof. I understand that requests to cancel or reschedule appointments are gladly accommodated with 24 hours notice and that short-notice cancellations/reschedule requests (less than 24 hours) and no-shows will be charged.

Signature:

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Confidential Hyaluron Intake Supplement