Cosmetic Injectables Consent Form
Patient Information
Patient Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Gender
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Please Select
Male
Female
Email Address
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example@example.com
Phone Number
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Area Code
Phone Number
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What procedure are you interested in?
Neurotoxin injection
Dermal filler
Please answer the following:
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Yes/No
Description/Remarks
Have you been treated for any dermal conditions?
Yes
No
Have you previously received neurotoxins injections or dermal fillers? If yes, when was the last time?
Yes
No
Have you ever been hospitalized? If yes, please indicate why and when.
Yes
No
Did you undergo any previous surgery? If yes, please indicate the procedure name, reason, and the date.
Yes
No
Do you have any known allergies? If yes, then please specify in the description field.
Yes
No
Are you currently taking medications? If yes, then please list the medications and the reasons why are you taking them.
Yes
No
What is your current medical condition? Do you have any communicable disease, cardiovascular problems, diabetes, asthma, etc.?
Yes
No
Are you pregnant, breastfeed, or nursing? (Female)
Yes
No
Emergency Contact Details
Contact Name
*
First Name
Last Name
Primary Phone Number
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Area Code
Phone Number
Secondary Phone Number
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Area Code
Phone Number
Acknowledgment, Authorization and Release
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I authorize Vydration to perform neurotoxin injections and/or dermal fillers.
I understand that neurotoxin injections are FDA-approved treatment that temporarily reduces muscle activity to smooth fine lines and wrinkles. The effects are not permanent and typically last 3-4 months.
I understand that dermal fillers are FDA-approved treatments that temporarily improve the appearance of wrinkles or enhance the shape and size of certain facial features.
I understand the advantages and disadvantages of this procedure. The injector explained the process thoroughly to me.
I understand that individual results may vary, and no guarantee is given regarding the outcome of the treatment.
I understand the side effects that I may experience after the procedure. Side effects may include nausea and vomiting; headache, body weakness, or paralysis of the affected area; facial alignment issue, bruising, drooping eyelids (ptosis) or uneven results; and/or allergy reactions, including rash or itching.
I release Vydration of any responsibility in case of an accident, illness, or injury.
I understand the risk and complications if I do not follow the instructions given to me after the procedure which involves post-treatment and follow-ups.
In the event of complications or concerning side effects, I acknowledge that I should seek immediate medical help from my healthcare provider or emergency services as needed.
I acknowledge that all information I provided in this form is true and accurate.
I have read and fully understand this consent form. I have had the opportunity to ask questions, which have been answered to my satisfaction. By signing below, I voluntarily consent to this procedure and assume all associated risks.
I confirm that I have disclosed any and all medical conditions, medications, allergies, and prior Botox treatments. I understand that failure to disclose this information could lead to complications for which I assume responsibility.
I authorize Vydration to take and use my before-and-after photos for medical records and/or promotional purposes. I understand that my identity will remain confidential unless I provide explicit written consent.
I fully release and discharge Vydration, its owners, employees, independent contractors, and affiliated medical professionals from any liability or responsibility for any complications, adverse effects, or dissatisfaction with the procedure results, except in cases of gross negligence or willful misconduct.
I understand that proper aftercare is essential to the success of the treatment. I agree to follow all post-treatment guidelines provided to me.
Denial of Service Clause: VYDRATION LLC reserves the right to refuse service to any customer or client at its sole discretion. This includes, but is not limited to, individuals who exhibit inappropriate behavior, fail to comply with company policies, present a health or safety risk, or engage in actions that may disrupt business operations. VYDRATION LLC also reserves the right to deny services if, in the professional judgment of our medical providers, the requested treatment is deemed unsafe, inappropriate, or medically contraindicated. No refunds will be issued for denial of service due to policy violations or failure to meet eligibility criteria.
By signing below, I confirm that I have read and fully understand this consent form. I have had the opportunity to ask questions, and my questions have been answered to my satisfaction. I consent to receive Botox treatment.
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Book Your Neurotoxin & Dermal Filler Appointment by calling us directly at 667-421-3340.
Date Signed
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Month
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Day
Year
Date
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