Lip Filler Intake Form

Effortless Ellegance By Felicia Fierro Phone 575.909.6151

Hepatitis Beef / Dairy / Allergy ?Sensitivity / Allergy to Lidocaine ?Neurological Disorders Severe Allergy / Anaphylaxis ?

Myasthenia / Gravis Porphyria / High Blood Pressure / Amytrophic Lateral Sclerosis ?

Eye Disease / Lambert-Eaton Syndrom / Hypersensitivity to medications Epilepsy/Seizures ?

Cold Sores / Fever Blisters / Keloid history ?

Low Blood Pressure / Cancer / Diabetes ?

Effortless Elegance

By Felicia Fierro 

575.909.6151

This consent form is designed to provide the necessary information to decide whether to undergo treatment with a hyaluron pen device.

This specific technique allows Hyaluronic Acid to be injected into the desired area in order to achieve the desired effect.

The aesthetic effect of the used fillers can last up to 6-8 months, depending on lifestyle, current skin condition, the area being treated and the amount of filler administered.

• I understand that I cannot receive this treatment if I have or I am epileptic, inflammation or infection, tendency to develop hypertrophic scarring, known hypersensitivity to hyaluronic acid, known hypersensitivity to lidocaine or local anesthetics, porphyria, diabetes, autoimmune disease, currently being treated with anticoagulants, blood diseases, blood coagulation disorders, pregnant or trying to get pregnant, malignant tumors, or under the age of 18.

‼️‼️‼️This treatment should not be injected into the areas of the skin that are prone to infection including areas affected by acne, herpes, cold sores, or fever blisters. This treatment should not be performed simultaneously with laser therapy, chemical peeling, or microdermabrasion.‼️‼️‼️

Side effects include but are not limited to inflammation, swelling, pain, erythema, itching, bruising, bleeding, compaction or nodules at the administration site, topical reoccurring breakouts of herpes and cold sores if not taken the correct steps given by the technician to avoid these. If you have any history of any of the above, please be sure to notify the tech. You will then be required to start and finish a 7 day course of Valacyclovir before your appointment time to ensure your body will not/can not attract any viral infections during your healing time.

• I have been informed about the benefits and possible complications involving hyaluron pen including anaphylactic shock, Quince's edema, fainting, post treatment swelling, bruising, and hematomas if I have any of the above underlying conditions  

• I consent to allow Felicia Fierro to consult with and evaluate me in order to determine if I am a good candidate for Hyaluron Pen. I understand that photographs will be taken and kept in my file. I agree that these forms have been completed truthfully and to the best of my knowledge and abilities. I understand the contraindications and

possible side effects of Hyaluron Pen as discussed with staff member of Effortless Elegance. Furthermore, Iagree to waive all liabilities toward Effortless Elegance for any injury or damages incurred due to my misrepresentation of my health history.

Effortless Elegance

By Felicia Fierro 

Phone 575.909.6151

I hereby grant Effortless Elegance the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures, video, and/or audio taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social media sites and other print or digital communications without payment or any

This authorization extends to all languages, media, formats, and markets now known and later discovered.

I will be consulted about the use of the photograph and/or video recording for any purpose other than those

promotional materials. printed and/or digital. educational presentations or courses. informational presentations.

online educational courses. educational videos.

There is no time limit on the validity of this release, nor is there any geographical limitation on where these materials may be distributed.

By signing this form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.

Effortless Ellegance By Felicia Fierro Phone 575.909.6151

We strive to render excellent care to you and the rest of our clients. Your care and treatment is a priority for us. We also ask that you respect your specialist's time and expertise as well.

In an attempt to be consistent with this, we have a Cancellation Policy that allows us to schedule appointments for our clients, with respect for your time, the next client's time, and the specialist's time.

We request that you give a notice not later than 24 hours prior to your scheduled appointment in the event that you cannot make it. If the client misses an appointment without contacting us, it is considered a missed or "No Show" appointment. Additionally, if a client is more than 15 minutes late for an appointment, it will be considered a "No Show" appointment, and that appointment will be rescheduled.

non refundable deposit will be paid at the time of making an appointment and will be taken

off at the time of the appointment.

If you have questions regarding this policy, please let us know, and we will be happy to clarify our policy

I have read and understand the Appointment Cancellation Policy, and I agree to be bound by its terms. I am aware that my credit card will be charged for the missed appointment, and I agree to these terms.

,have received the copy of Cancellation Policy