Hyaluron Pen Consent Form

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

I grant permission to Pixie Beauty Studio LLC to use my before and after photos for marketing or examples of my technicians work. *We will make you look GLAM!*

I release Pixie Beauty Studio LLC. from any and all liability associated with this procedure. This service will be performed with the utmost attention to safety, sanitation, and proper application using tools and products that the technician has been trained and certified to use.

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I acknowledge and understand that the studio doesn't offer refunds. Pixie Beauty Studio LLC will do their ultimate BEST to provide a service experience to meet your satisfaction and expectations to LOVE your lips every appointment.

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I acknowledge Pixie Beauty Studio LLC does their full effort to fulfill my appointments times and I respectfully acknowledge the times I schedule to be available. I understand the following set CANCELLATION policies that are also non-refundable agreements of service. If you cancel or reschedule 24 hrs before your appointment, a 50% fee will be charged upon cancellation. Second cancellation offense, you will be charged the full appointment amount. If you cancel often you will be no longer able to book with Pixie Beauty Studio LLC. NO-SHOW / NO-CALL will be charged 100% of service amount. If you are running late, please communicate by sending me a message. If you are 10 minutes late you will need to pay the $10 late fee.If you're more than 10 minutes late in total your appointment will be CANCELED. While things may happen, we advise appropriately booking.

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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 throughly read below and fill out the information required to express your intention in undergoing the treatment.

INTRODUCTION

At Pixie Beauty Studio, we are excited to offer a revolutionary way to enhance your lips without the use of needles. Hyaluronic Acid treatments involve injecting purified Hyaluronic Acid into the lips.

Our NEEDLE - FREE injections use advanced pressure technology to gently and precisely deliver hyaluronic acid into your lips, giving you a fuller, more defined pout with minimal discomfort and no downtime. This innovative treatment is perfect for those looking to achieve natural-looking volume and hydration, all while enjoying a more comfortable and less invasive experience.

Hyaluronic acid is naturally produced by your body that keeps your skin / lips well lubricated and moist. 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 6 months or longer. Since this is not permanent, a treatment every 6 months - 12 months may be required for best 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:

Have you had allergic reactions to hyaluronic products?

Have you had allergic reactions to Lidocaine products?

Are you anaphylactic to anything or do you have a history of any serious allergic reactions?

Do you have a history of Keloids?

Are you pregnant or breastfeeding?

Any recent dental/facial surgery?

Have you been diagnosed with any viral infections such as herpes or simplex (cold sores)?

Do you take any medications that aren’t over the counter?

RISKS

The following are the possible risks that Hyaluronic Acid treatment may cause, please initial are

I understand that I may experience pain and tenderness at or around the treated area that typically resolves within a few days to a week.

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I understand itchiness, redness, and/or swelling at or around the injection area may occur. This occurrence 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 a couple weeks.

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I understand that in rare occasions, pustules (acne-like lesions) may form. If such occurrence happens I shall notify the Pixie Beauty Studio as soon as possible.

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I understand that taking medications such as ( aspirin, ibuprofen, and naproxen ) have a higher risk of causing bruising and bleeding.

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I understand that infection may happen at the treated area, if not properly following after care steps.

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I understand there are very rare cases where the injection of Hyaluronic acid into a blood vessel would cause to block the blood flow in the treated area or in distant areas causing tissue damage. If this does occur please notify Pixie Beauty Studio.

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I understand that grayish discoloration on the treated area of the skin is extremely rare but this may persist from a few weeks to several months and may be permanent (rarely).

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I understand that, Asymmetry, where the correction on one side may be different from the correction on the other side of the face. If this occurs I will need to come back for another treatment to make the lips symmetrical.

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I read and fully understand the risks mentioned above, as well as other risks which may not fully be known.

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.

Date

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