Hyaluron Pen Consent Form

Name:*

First NameLast Name

Birth Date:*

Date

Phone Number:*

Please enter a valid phone number.

Email:

example@example.com

Procedure desired:*

Are you a client or model?

If you are interested in being a model for any of our services please register online. www.MarisGoddessEffects.com/models *Please note model services are completed by students under instructor's supervision.

How did you hear about our salon?

Thank you for your interest in the Hyaluronic Pen Treatment. This form is intended to provide you the information you need in order to make informed decisions about the treatment. Please read through below and fill out the information required to express your intention in undergoing the treatment.

INTRODUCTION Hyaluronic Acid treatments involve injecting purified Hyaluronic Acid into the skin. This fills the wrinkles and restores volume. Hyaluronic acid is naturally produced by your body that keeps your skin well lubricated and moist. We lose this as we age. This treatment is intended to retain Hyaluronic acid in our skin. But, just like natural Hyaluronic Acid, the injectables eventually lose their form and wears down in due time. The injectable Hyaluronic Acid can last around 3-6 months or longer. But since this is not permanent, a periodic treatment may be required for body retention.

PATIENTS THAT MAY NOT BE ELIGIBLE FOR THE TREATMENT Due to certain health conditions, some may not be allowed or may be evaluated further to take this treatment. This is for the protection of the health and safety of the patient. We have enumerated here the following conditions that may prevent the patient to undergo the Hyaluronic Acid treatment and thus the injector must be notified: Those who had allergic reactions to hyaluronic products Those who are anaphylactic or having a history of a serious allergic reaction Those who are Keloid formers Those who are pregnant or nursing a child Those who recently had dental/facial surgery. Those who have viral infections such as herpes or simplex (cold sores) Those who are under medication

RISKS The following are the possible risks that Hyaluronic Acid treatment may cause (please check each item as an express of your acknowledgment to the risk):

Pain and tenderness at or around the treated area that typically resolves within a few days to a week.*

I understand that I might experience this during or after treatment and I understand that this resolves typically from a few days up until a week

Itchiness, redness, and/or swelling at or around the injection may occur. This occurence is normal and happens immediately after treatment and will disappear after a few days or up to a week. Some patients may experience prolonged swelling and/or tenderness/pain at the injection site lasting up to several weeks.*

I understand that I might experience the statement above

In rare occasions, pustules (acne-like lesions) may form.*

I understand that I might experience the statement above. In such occurrence, I shall notify the clinic as soon as possible

Persons taking medications have a higher risk of bruising and bleeding.*

I understand that I might experience the statement above.

Infection may happen at the treated area*

I understand that I might experience the statement above. I understand that this may require antibiotics. In any case, I shall notify the clinic should this happen

There are very rare cases where the injection of Hyaluronic cid into a blood vessel would cause to block the blood flow in the treated area or in distant areas causing tissue damage*

I understand that in the event I experience this, I might need to undergo surgery for correction

Grayish discoloration on the treated area of the skin.*

I understand that this may persist from a few weeks to several months and may be permanent (rarely).

Asymmetry, where the correction on one side may be different from the correction on the other side of the face*

I understand that this may happen. In such occurrence, I might need to return for additional treatment for correction purposes.

Do you have any medical conditions?*

YesNo

Please list any medical conditions and/or medications you are currently taking.

Please include all, Prescription and over the counter

I read and fully understand the risks mentioned above, as well as other risks which may not fully be known. Nonetheless, I understand and assume all the risks involved in the treatment. I release, waive, and forever discharge the clinic, its employees, staff, directors, partners, and affiliates from any or all injuries, damages, or death that may occur during or after treatment that may be caused by said treatment. I declare that I am of legal age with the full legal capacity to execute and bind myself to this consent. I have had the opportunity to ask questions that are unclear to me and answers were given to me by the clinic's representative to my satisfaction. By signing this form, I give my consent in full consideration and understanding without any representation, coercion, or inducement.

Signature*

Clear

Date*

Date

Photography and Videography Release Consent

Mari's Goddess Effects insurance company requires "Before" and "After" photos/videos be taken and kept on file. We would like your permission to use these photos/videos for advertising. For example, in portfolios,online and in print adds, etc. Your consent is necessary regarding this.

Signature*

Clear

Please read and screenshot or download the PDF below.

1133 Oak St. North Aurora Illinois 50542