CONSENT & AUTHORIZATION FOR TREATMENT

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Full Name

First Name

Last Name

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Phone Number

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Date of birth

Date

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How did you hear about us?

Instagram, Friend, Etc.

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Have you ever had any previous filler?

Yes

No

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I, the undersigned, hereby consent to and authorize Nina Nacole Ramirez, Lip Filler Specialist, to perform a needleless lip filler treatment using a HyaPen device to infuse hyaluronic acid into the lips and surrounding tissue. I also authorize the use of microneedling techniques on the lips if deemed necessary to enhance product absorption, improve texture, or support overall treatment results.I certify that I am at least 18 years of age and am voluntarily choosing to undergo this procedure after having the nature, purpose, and expected outcomes explained to me.I understand that this treatment involves the use of hyaluronic acid and/or microneedling and may include risks such as, but not limited to: swelling, bruising, tenderness, redness, uneven results, infection, allergic reaction, or other unforeseen complications. I acknowledge that individual results vary based on factors including age, skin condition, and lifestyle, and that additional treatments may be required to achieve desired results at an additional cost.I confirm that I have disclosed all relevant medical history, including allergies, medications, skin conditions, and any contraindications such as pregnancy, breastfeeding, or sensitivity to hyaluronic acid. I understand that failure to provide accurate information may increase the risk of complications.I acknowledge that all equipment used is properly sanitized and that appropriate hygiene protocols are followed; however, I understand that no procedure is completely risk-free. I accept these risks and agree to release Nina Nacole R from any liability, except in cases of gross negligence.I grant permission for photographs and/or videos to be taken and used for educational, marketing, and social media purposes, including but not limited to Instagram, Facebook, and TikTok.I understand that no guarantees have been made regarding the outcome of this treatment. I agree to follow all pre-care and aftercare instructions provided and will contact my technician if I have any concerns.By signing below, I confirm that I have read, understand, and agree to all terms outlined above. I accept full responsibility for any risks, side effects, or complications that may arise.

Signature at the bottom of page.

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Date

Todays date

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Client Signature