Client Intake - Home Rejuvenation

Botulinum A Toxin (Botox/Dysport/Xeomin/Jeuveau) injections are most commonly used to temporarily relax the facial muscles that cause wrinkles in the forehead and around the eyes. The injected muscle can't contract which makes wrinkles relax and soften. Botox cannot stop the process of aging, but it can temporarily diminish the look of wrinkles caused by muscle groups.

Please read and initial the following:
I confirm I have not received any other botulinum toxin product within the last 3 months.I understand that the results are temporary and the duration of effect generally lasts for approximately about three months. Continuing treatments are necessary in order to maintain the effect over time.
I understand that it generally takes 14 days to take effect. As muscle action slowly returns, the lines and wrinkles begin to reappear and need to be treated again.
The information I have provided about my medical history is accurate to the best of my knowledge, including all known allergies and/or prescription drugs/products I am currently ingesting or using topically.I understand how important it is that I follow all post-treatment home care instructions. In the event I may have additional questions or concerns regarding my treatment or post-treatment care, I will consult Homa Rejuvenation Center immediately.
I understand I may have some temporary side effects after the Botox injections. These include but are not limited to: mild pain and swelling around the injection sites, bruising, eyelid drooping, headache, nausea, facial asymmetry, blurred or double vision, crooked smile, eye dryness or severe tearing, numbness and weakness in nearby muscles.
I hereby give my informed consent to proceed with Botox injections. I have read and fully understand this agreement and all information detailed above. I understand the procedure being performed today and accept all possible risks. I have had all contraindications and possible side effects of Botox explained to me and my questions have been answered to my satisfaction. I do not hold Homa Rejuvenation Center or the Provider performing the procedure responsible for any liability associated with this procedure. I consent to the terms of this agreement.

I confirm that I am at least 18 years of age and by signing this Consent Form, I agree to waive all liability towards my Provider and Homa Rejuvenation Center for any injury or damages incurred due to any misrepresentation of my medical history.
NAME PRINTED*
SIGNATURE*

Clear
DATE*

MonthDayYear
Date

Dermal Filler Injections (i.e. Restylane, Juvederm, Voluma, Radiesse, Sculptra) are commonly used to smooth moderate to severe facial wrinkles and folds around the nose and mouth, add volume to lips or shape facial contours. The fillers used have been FDA approved for the cosmetic treatment of moderate to severe facial wrinkles and soft tissue depressions.

Please read and initial the following:
I understand that the results of dermal fillers are temporary and the duration of effect generally lasts for approximately six months.
I am aware and accept that no guarantees regarding the result of this procedure have been made or implied.I understand that after the first treatment, additional treatments may be necessary to achieve the desired level of correction. Full correction is not guaranteed after one treatment and complete symmetry may not be achieved.The information I have provided about my medical history is accurate to the best of my knowledge, including all known allergies and/or prescription drugs/products I am currently ingesting or using topically.
I understand how important it is that I follow all post-treatment home care instructions. In the event I may have additional questions or concerns regarding my treatment or post-treatment care, I will consult Homa Rejuvenation Center immediately.
I understand I may have some temporary side effects after the dermal filler injections. These include but are not limited to: redness, swelling, pain, itching, discoloration, bruising or tenderness at the injection site or allergic reaction. Post treatment bacterial, viral and/or fungal infections can occur which in most cases can be easily treated.
I hereby give my informed consent to proceed with Dermal Filler injections. I have read and fully understand this agreement and all information detailed above. I understand the procedure being performed today and accept all possible risks. I have had all contraindications and possible side effects of Dermal Fillers explained to me and my questions have been answered to my satisfaction. I do not hold Homa Rejuvenation Center or the Technician performing the procedure responsible for any liability associated with this procedure. I consent to the terms of this agreement.

I confirm that I am at least 18 years of age and by signing this Consent Form, I agree to waive all liability towards my provider and Homa Rejuvenation Center for any injury or damages incurred due to any misrepresentation of my medical history.
NAME PRINTED*
SIGNATURE*

Clear
DATE*

MonthDayYear
Date

I hereby give consent and grant permission for Homa Rejuvenation Center to use specified photographs and/or video taken before, during and after the treatment/procedures of me to use for the following purposes
To be shown to clients and potential clients as well as educational purposesAll purposes, including marketing purposes in all mediaUse in my chart only
I hereby waive any right to inspect or approve the finished photographs and/or video. I release Homa Rejuvenation Center from harm or detrimental consequences that maybe experienced as a result of usage of these images in these ways.

Additionally, I waive my right to payment, royalties or any other compensation that may arise from the use of these photographs and/or video. I release my images from confidentiality requirements as agreed.

I confirm that I am at least 18 years of age and by signing this form, I acknowledge that I have completely read and understood the above release and agree to be bound thereby.
NAME PRINTED*
Signature*

Clear
DATE

MonthDayYear
Date

At Homa Rejuvenation Center, your appointments are very important to us, and we understand that sometimes appointments need to be re-scheduled or canceled. Because most of our services require preparation time to properly prepare a room for your treatment, we have Cancellation Policies in place.
In order to provide you and others with excellent customer service and access to appointments during peak times, we kindly ask for the following considerations:

CANCELLATION POLICY & FEES
- We respectfully request at least 24 hours notice to cancel or reschedule your appointment.
- Less than 24 hours notice will result in a charge equal to 50% of the reserved service amount.
- All "NO SHOWS" will be charged 100% of the reserved service amount.
This cancellation policy allows us time to inform our standby guests of any availability. Without sufficient notice, we end up turning away other clients who could have scheduled an appointment for the same time.

ARRIVAL TIME

Please arrive for your appointment 5 minutes before your scheduled appointment time. This allows for extra time to attend to your paperwork etc. Arriving early will not guarantee your service will start before your scheduled appointment time.

LATE ARRIVALS

We understand that sometimes things happen outside of your control to make you late for your appointment. We will do everything we can to accommodate you, but unfortunately it will limit the time allocated for your treatment or we may need to reschedule your appointment. If we have to reschedule your appointment, you will be responsible for 50% of the value of the original service(s).

Please let us know as soon as possible if you are running late so we can best accommodate everyone.

Thank you for viewing and supporting our policies criteria.

I have read and understand the Cancellation Policies listed above and agree to abide by the above conditions.
NAME PRINTED*
SIGNATURE*

Clear
DATE*

MonthDayYear
Date
Should be Empty:

CLIENT INFORMATION

MEDICAL HISTORY

I hereby give consent and grant permission for Homa Rejuvenation Center to use specified photographs and/or video taken before, during and after the treatment/procedures of me to use for the following purposes