Informed Consent Form
Youthful Reflections, LLC
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Emergency Contact Name and Relationship
*
Emergency Contact Number
*
Allergies (food, medication, environmental)
*
Past reaction to anesthetics (such as lidocaine, prilocaine or tetracaine)
*
Current medications, supplements and medicated topical creams and ointments
*
Please select those that apply:
Cancer
Diabetes
Hysterectomy
HIV/AIDS
Psoriasis
Eczema
Keloid scaring
Rosacea
Cold sores
Veins, Phlebitis
Varicose veins
Congestive heart failure
Severe kidney impairment
Sodium retention/Swelling/Water retention
Electrolyte
Severe frequent headaches
Heart Attack
Stroke
Diabetes/Low blood sugar
Asthma
Fainting/Seizures/Epilepsy
High blood pressure
Low blood Pressure
Any Liver Conditions - Cirrhosis, Fatty Liver Disease, etc
Females Only - Are you pregnant or trying to become pregnant?
Please Select
Yes
No
Females Only - Are you breastfeeding?
Yes
No
Have you been diagnosed with a blood-transmissible disease (Hepatitis B or C, HIV)?
*
Please Select
Yes
No
I understand the above information is necessary so that I may be provided with the best possible care. I have answered all questions truthfully and honestly and to the best of my knowledge.
*
I agree.
I have informed the staff of any known allergies to drugs or other substances, or of any past reactions or anesthetics. I have informed the staff of all current medications and supplements I'm taking. I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and give my concerns.
*
I agree
I grant Youthful Reflections, its representatives and employees the right to take photographs of me in connection with receiving any treatments from Youthful Reflections. I authorize Youthful Reflections, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Youthful Reflections may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, social media and web content.
*
I agree
I do NOT agree
Today’s Date
*
-
Month
-
Day
Year
Date
My signature signed below indicates my acceptance of the terms and conditions.
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