HyaPen Filler & Fat Dissolve

Full Name*

First Last

E-mail*

We will never SPAM or sell email addresses to third parties.

Birthdate:*

ex. 01/05/1960

Phone:*

ex. 555-555-5555

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Who referred you to skinSPArations?*

Please read and initial each of the statements below:

I certify I am over the age of 18. I have voluntarily elected to receive HyaPen Fillers and/or Fat Dissolve treatments and the nature and purpose of this treatment has been explained to me.*

Initial

I understand that HyaPen Fat Dissolve treatments can be used to reduce unflattering and stubborn areas of fat and cellulite without the need for liposuction or surgery. I recognize there are no guaranteed results and every body responds differently to treatment. I understand and agree treatments can be received every 10-14 days*

Initial

I understand that HyaPen Filler treatments can be used to create volume, shape and lift in many areas of the face I recognize there are no guaranteed results and every body responds differently to treatment. I understand and agree my first Touch Up appointment can be made 2-3 weeks after my inital appointment and 3 months thereafter.*

Initial

I have the Before/After Care instructions and FAQ section on www.skinSPArations.com and am informed of possible benefits, risks, and complications, and I have had the opportunity to ask questions regarding these risks and other possible complications*

Initial

I understand that the following conditions preclude me from having Hyapen Filler & Fat Dissolve at this time and verify that none of the following conditions apply to me at this time:

History of a serious allergic reaction (anaphylactic)
Abnormal raised scarring or keloid formation
Active inflammation or infection in the treatment area (e.g. pimples, rash, hives)
Pregnancy, or Nursing or recent dental/facial surgery
Autoimmune Disease such as Hepatitis, HIV/AIDS, Diabetes
Blood Clotting Disorder

Additional Fat Dissolve Conditions:

Oncology
Eplieptic seizures
Disorders of Hematopoietic apparatus

Initial

I understand and acknowledge that there are risks involved with the treatment I will be receiving including, but not limited to: • Bruising • Redness • Swelling • Irritation • Skin reaction • Increased heart rate*

Initial

I understand I cannot get HyaPen Fillers for at least 30 days since my last Botox or Filler from another provider*

Initial

I understand and will follow me Pre Treatment Guidelines:

Do not take any aspirin, ibuprofen or similar products (Advil, Motrin, Aleve) for one week prior to procedure
Avoid fish oil, Vitamin E, and gingko biloba for 1 week prior to this procedure
Eat spinach, kale and celery the week before to boost your levels of Vitamin K
Hyaluronic acid tend to be the most temporary option, and therefore are often recommended for first-time clients
The results will typically last 3-4 months, and injections to the lips will wear out a little faster than those to the nasolabial folds. * Keep in mind that results may vary

I will also follow my Post-Care Guidelines that will be provided at the time of my appointment to ensure optimal results.

Initial

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 irritation to the skin from treatments received. I am aware that it is my responsibility to inform the aesthetician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release skinSPArations and/or the skin care professional from liability and assume full responsibility thereof.

I understand and agree*

Initial

To cancel an appointment please text 920-216-5338 or email skinSPArations@gmail.com at least 24 hours prior to your appointment. Cancellations or Reschedule less than 24hrs notice will be subject to the following:

First occurance 50% charge of service, after that 100% charge of service
No Show or Missed Appointments 100% charge of service

I agree to the cancellation policy*

Initial

I understand before/after photos will be taken for legal and progession purposes as and grant permission to skinSPArations to use photos of my progress for marketing purposes on www.skinSPArations.com or other business listing pages.

I agree to the photo release*

By signing below, I agree to the following:
I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my technician and the salon for any injury or damages incurred due to any misrepresentation of my health.

Client Full Name*

First NameLast Name

Signature*

Date*

Date

HyaPen Filler & Fat Dissolve Form