Aesthetic New Patient Consent Form

Patient Basic Information Form:

to be filled out by the patient seeking aesthetic services
Full Name*

First NameMiddle InitialLast Name
Gender*
Birth Date*

MonthDayYear
Date
Age*
Phone Number*
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact*
First and Last Name
Emergency Contact Phone Number*
Please enter a valid phone number.

How did you hear about Better Beauty & Wellness, LLC?*
Referral's Name (they will get $20 off their next service!)*
First and Last Name
Party Host's Name*
First and Last Name
Other*

Medical History

to be filled out by the patient
Are you under a doctor's care at the present time?*

YesNo
If yes, please explain:
Are you pregnant or breastfeeding?*

YesNo
Do you have allergies to any medications?*

YesNo
Medication*
Reaction*
Medication
Reaction
Medication
Reaction
Are you currently taking any medications?*

YesNo

Medical & Skin History: Do you currently or have you ever had any of the following?*

	Yes or No	Please explain/elaborate:
Herpes
Sensitivity to Anesthetic
Lupus
Photosensitive Disorder
Autoimmune Disease
Keloid Scars
Skin Cancer
Cold Sores
Skin Infections
Hypersensitivity to Skin Products
Use of Acne Products/Drugs
Laser Skin Resurfacing
Chemical Peels
Laser Work of Any Kind
Currently Pregnant or Breastfeeding
Other

I attest the medical history provided is true, knowing my provider relies on this information to provide safe and effective treatment.*

Clear
Date*

MonthDayYear
Date
What products are you interested in?*

Botox/DysportDermal FillersBoth
What areas (see image below) are you interested in treating?

Informed Consent for Botulinum Toxin Injection

Botulinum Toxin Type-A as Botox® or Dysport®
1. Botox®/Dysport® is the botulinum toxin and works by paralyzing nerves and muscles. I, {fullName3} , consent to and authorize Kelli DiMattia, FNP to perform a treatment of facial wrinkles with Botox®/Dysport®.

2. The nature and purpose of the treatment has been explained to me and questions I have regarding the treatment have been answered to my satisfaction.

3. I, {fullName3}, understand surgery or other treatment alternatives may be as effective or more effective in reducing the appearance of wrinkles.

4. I, {fullName3}, am fully aware of the risks and complications or injuries that can occur from this treatment, both from known and unknown causes, and I freely assume those risks.

The known complications and effects could include:
- Redness, swelling/edema, itching, pain or pressure lasting more than a week
- Nodules or induration at the injection site
- Discoloration of the injection site
- Poor effect
- Allergic reaction
- Bruising
- Facial asymmetry
- Paralysis leading to droopy eyelid and double vision
- Some patients may experience weakness or flu-like symptoms
- Dry eyes
- The effects Botox®/Dysport® are apparent 3-5 days after treatment, and may take longer to fully set in
- The effects usually last 3-4 months
- Periodic treatment will be necessary to maintain the effects of Botox®/Dysport®
- Repeated treatment may lead to permanent loss of muscle tone in the treated area
- Some patients may develop antibodies to Botox®/Dysport®
I, {fullName3}, certify that I have none of the known conditions that would contraindicate treatment. These conditions include; hypertrophy scars, a history or any autoimmune disease, or immune therapy. I am not pregnant, breast-feeding, and I have no known allergy to Botox®/Dysport®.

No guarantees, warranty or assurance has been made as to the treatment results.

I will hold Better Beauty and Wellness, LLC, its owner(s), agents, providers, employees and shareholders completely harmless from all and any litigation or claims made, should I have any adverse reactions to Botox®/Dysport®. Further, I hold Better Beauty and Wellness, LLC completely harmless from any and all malpractice suits or claims made in relation to my receiving Botox®/Dysport®. All complications should be seen in the emergency room or by your local physician. No clinical follow-up is provided by the provider. Any subsequent care or corrections would be at your own cost and without compensation from Better Beauty and Wellness, LLC, the provider or the employees. Better Beauty and Wellness, LLC and its providers maintain the right, under all circumstances and without penalty, to not perform the procedure should the decision be made by them.

I understand that the results are of temporary nature, and more treatments will be needed to maintain improvement. I agree to adhere to all safety precautions described here including:
- NO laying down or reclining for (4) hours after injection(s)
- NO scratching or rubbing the injected area
- NO bending forward for (4) hours
- Make-up should be avoided for (1) to (2) hours after injection(s)
This agreement is non-transferable and may not be altered by anyone without the express written consent of the provider. This agreement does not expire.

I, {fullName3}, certify that I have read this entire informed consent and that I understand and agree to the information in this form. I certify that I am a competent adult of at least 18 years of age, or that if I am a minor under the age of 18, I understand that the consent of my parent/legal guardian will also be required for treatment. This informed consent is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assigns.
Signature*

Clear
Date*

MonthDayYear
Date

Informed Consent for Dermal Fillers
The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives of the procedure named above. This material serves as a supplement to the discussion you have with your doctor/healthcare provider. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing the consent form.

THE TREATMENT
Treatment with dermal fillers (such as Juvederm, Restylane, Radiesse and others) can smooth out facial folds and wrinkles, add volume to the lips, and contour facial features that have lost their volume and fullness due to aging, sun exposure, illness, etc. Facial rejuvenation can be carried out with minimal complications. These dermal fillers are injected under the skin with a very fine needle. This produces natural appearing volume under wrinkles and folds which are lifted up and smoothed out. The results can often be seen immediately.

RISKS AND COMPLICATIONS
Before undergoing this procedure, understanding the risks is essential. No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalization, and/or extended outpatient therapy to permit adequate treatment. It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure and in this specific instance such risks include but are not limited to: 1) Post treatment discomfort, swelling, redness, bruising, and discoloration; 2) Post treatment infection associated with any transcutaneous injection; 3) Allergic reaction; 4) Reactivation of herpes (cold sores); 5) Lumpiness, visible yellow or white patches; 6) Granuloma formation; 7) Localized necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occurs.

PREGNANCY AND ALLERGIES
I, {fullName3}, am not aware that I am pregnant. I am not trying to get pregnant. I am not lactating (nursing). I do not have or have not had any major illnesses which would prohibit me from receiving dermal fillers. I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to lidocaine.

ALTERNATIVE PROCEDURES
Alternatives to the procedures and options that I have volunteered for have been fully explained to me.

RIGHT TO DISCONTINUE TREATMENT
I, {fullName3}, understand that I have the right to discontinue treatment at any time.

RESULTS
Dermal fillers have been shown to be safe and effective when compared to collagen skin implants and related products to fill in wrinkles, lines, and folds in the skin on the face. Its effect can last up to 6 months. Most patients are pleased with the results of dermal fillers use. However, like any esthetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that wrinkles and folds will disappear completely, or that you will not require additional treatment to achieve the results you seek. The dermal filler procedure is temporary and additional treatments will be required periodically, generally, within 4-6 months, involving additional injections for the effect to continue. I am aware that follow-up treatments will be needed to maintain the full effects. I am aware the duration of treatment is dependent on many factors including but not limited to: age, sex, tissue conditions, my general health and lifestyle conditions, and sun exposure. The correction, depending on these factors, may last up to 6 months and in some cases shorter and some cases longer. I have been instructed in and understand the post-treatment instructions.

I understand this is an elective procedure and I hereby voluntarily consent to treatment with dermal fillers for facial rejuvenation, lip enhancement, establish proper lip and smile lines, and replacing facial volume. The procedure has been fully explained to me. I also understand that any treatment performed is between me and the doctor/healthcare provider who is treating me and I will direct all post-operative questions or concerns to the treating clinician. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure and I understand that no guarantees are implied as to the outcome of the procedure. I also certify that if I have any changes in my medical history, I will notify the healthcare professional who treated me immediately. I also state that I read and write in English.
Signature*

Clear
Date*

MonthDayYear
Date

Financial Policy

Thank you for selecting Better Beauty and Wellness, LLC for your health care. We are honored to be of service to you and your family. This is to inform you of your billing requirements and our financial policy. Please be advised that payment for all services will be due at the time services are rendered. For your convenience we accept Visa, Mastercard, Discover, American Express, Venmo, HSA/FSA cards, and CareCredit.
I have read and understand the above and agree to the financial policy:*

Clear
Date*

MonthDayYear
Date
HIPAA Privacy Notice

I understand that Better Beauty & Wellness, LLC follows The HIPAA Privacy Rule which requires appropriate safeguards to protect the privacy of protected health information and sets limits and conditions on the uses and disclosures that may be made of such information without your authorization. The Rule also gives you rights over your protected health information, including rights to examine and obtain a copy of your health records, request corrections, or request it be sent to another party.
I have read and understand the HIPAA Privacy Notice:*

Clear
Date*

MonthDayYear
Date

Can't wait to see you!

If you have questions, you can contact me using the information below -- otherwise go on and hit submit!
Should be Empty:

	Name of Medication	Prescription or Over-the-Counter?	Dosage	Schedule
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6

Patient Basic Information Form:

Medical History

Informed Consent for Botulinum Toxin Injection

Informed Consent for Dermal Fillers

Can't wait to see you!