PATIENT INTAKE FORM

INFORMED CONSENT & WAIVER
I understand that  some procedures may cause mild redness, swelling, or tenderness at the injection site. I acknowledge that individual results may vary and that multiple sessions may be required for optimal results. 

I confirm that I have disclosed all relevant medical history and understand that failure to do so may increase the risk of adverse effects. I consent to receive the treatment and acknowledge that I have been informed of the risks, benefits, and expected outcomes.

TREATMENT DECLINE DUE TO FISH ALLERGY
Some treatments, such as salmon DNA, may contain ingredients derived from fish, which may cause allergic reactions in individuals with fish allergies. As patient safety is our top priority, we cannot proceed with these types of treatments for patients with a confirmed fish allergy.

By signing below, I acknowledge that I have been informed about the risks associated with my allergy and understand that I am not eligible for the Nucleofill treatment. I confirm that I have discussed alternative treatment options with my provider.