Medical Intake form

Date*

Date

Name*

First NameLast Name

Email

example@example.com

Phone Number*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Date

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.

Have you had any changes since your previous visit?*

YesNo

If yes, please explain. If no, please proceed to the signature page.

Do you have any allergies?

YesNo

If yes, please list.

Have you had any cosmetic treatment before?

YesNo

If yes, please explain.

Medical History

	Yes	No
Alopecia
Bleeding Disorders
Eczema/Rashes
Hepatitis
Pregnant or breastfeeding
Recent scar tissue
Recent permanent makeup
Sunburn
Use of Alpha, Hydroxy Acid
Ultra sensitive skin
Blood thinners
Chemotherapy
Fillers/Botox
HIV/AIDS
Recent chemical peel
Recent surgery
Skin Cancer
Seizures
Use of Acutane, Renova, or Retin-A
Varicose veins

Other medical conditions you want us to know about

Are you on any blood thinners?

YesNo

Current medications including vitamins, herbal supplements, hormones and topical medications.

Are you pregnant or trying to get pregnant?

YesNo

If yes, please explain.

Do you have any implants?

YesNo

If yes, please explain.

Have you had any Botox or Dermal filler treatments recently?

YesNo

If yes, please explain and let us know when.

Have you had any adverse reactions to any previous treatment?

YesNo

If yes, please explain.

Have you exfoliated or applied any products to your face in the last 24 hours?

YesNo

If yes, please explain.

Have you had any reactions to any of the following?

	Yes	No
Aspirin
Neurotoxin
Lidocaine
Collagen
Eggs
Hydrocortisone

If yes, please explain.

SIGNATURE PAGE

INFORMED CONSENT FOR DERMAL FILLER

- Dermal filler is a non-surgical cosmetic treatment used to enhance and restore the youthful appearance of the skin. it typically involves injecting a substance, such as hyaluronic acid or collagen, into specific areas of the face or body to smooth wrinkles, add volume, and improve the overall texture of the skin. Dermal Fillers can be used to treat fine lines, deep wrinkles, nasolabial folds, marionette lines, and to add volume to the lips and cheeks. They are also employed for facial contouring and scar correction. The effects of dermal fillers are generally temporary and may last from several months to over a year, depending on the type of filler used. Dermal Fillers are administered by trained healthcare professionalsand are a popular choice for individuals seeknig to rejuvenate thier appearance without undergoing invasive surgery.

- Dermal fillers typically include substances that are injected into the skin to enhance its appearance and address various cosmetic concerns. The key componets of dermal filler include:

- Hyaluronic Acid: This is the most comone ingredient in many dermal fillers. Hyaluronic acid is natural substance found in the body that helps maintain skin hydration and volume. It's used to add moisture and plumpness to the skin, reducing the appearance of wrinkles and fine lines.

- Collagen: Some dermal fillers contain collagen, a protein that supports the skins structure and elasticity. Collagen-based fillers help to restore volume and smooth out lines and wrinkles.

- Calcium Hydroxylapatite: This mineral-like compound is used in dermal fillers to provide support and structure to the skin. It's often used for deeper wrinkles and facial contouring.

- Poly-L-lactic Acid: This bicompatible and biodegradeable synthetic substance stimulates collagen production in the skin. It's used for gradually improving skin texture and treating fine lines and wrinkles.

- Polymethyl Methacrylate (PMMA): Tiny PMMA microspheres are suspended in a gel and used in some dermal fillers. They provide a semi-permanent solution for wrinkles and depressions in the skin.

- Others: There are also some specialized dermal fillers that may include different substances depending on the specific brand and type. These may include lidocaine (a local anesthetic) for enhanced comfort during the injection.

INFORMED CONSENT FOR BOTOX AND NEUROTOXIN

"Botox" is one of the most familiar brands of botulinum toxin injections. Botulinum toxins are neurotoxins that impact nerves, leading to muscle weakening. These injections serve both cosmetic and medical purposes. Practitioners administer small quantities of botulinum toxin into specific areas to reduce wrinkles, prevent migraines, and manage a broad spectrum of other health conditions.

Botox works by blocking nerve signals to muscles, resulting in the temporary inability of the injected muscles to contract. This effect typically lasts for about three to four months. The specific muscles that are injected depend on the areas of concern, and it's possible to treat multiple areas during a single session.

RISK & COMPLICATIONS

For every treatment, there are inherent risks involved. It is crucial that you thoroughly comprehend these risks before proceeding with the treatment. While providing a complete medical history can help reduce these risks, there may still be unforeseen complications that may arise. If you have any concerns about these risks, do not hesitate to reach out to your healthcare professional.

The potential risks and complications include:

- Allergic reaction

- Infection

- Bruising

- Skin irritation

- Headaches

- Blurred vision

- Eye dryness or tearing

- Swelling

- Scarring of the skin

- Increased sensitivity

- Anaphylaxis

It's essential to consult with a qualified healthcare provider to address any concerns and assess your individual risk factors before undergoing any treatment.

In rare cases, botulinum toxin may extend beyond the intended treatment area, resulting in botulinum-like signs and symptoms. These may include breathing difficulties, trouble swallowing, muscle weakness, and slurred speech. If you experience any of these unuswal symptoms following treatment, it is imperative to seek immediate medical attention.

CONSENT

- During the course of the treatment, despite all precautionary measures taken by the technician, it's important to recognize that there is a possibility of injury. I will not hold the technician responsible for any issues that may arise as a result of undergoing the procedure.

- I understand that there are inherent risks associated with botulinum toxin/Botox and dermal filler. If I experience any form of adverse reaction, I will promptly seek medical attention and inform my technician.

- It is my responsibility to communicate any concerns I may have to the technician before the procedure.

- I understand and agree to follow the aftercare instructions provided by my technician. I am aware that not adhering to the aftercare instructions may impact the achievement of the desired results.

- I acknowledge that the product will be injected into the muscles of my face as part of the botulinum/Botox process. The technician performing the procedure will not be held liable for any damages to my skin or me for any reason, especially if I fail to follow aftercare instructions.

- I have disclosed all pertinent medical history, and I commit to informing my technician of any changes that may occur in the future.

By signing below, I hereby acknowledge that I have read and understand all the information in this informed consent agreement. I understand that this agreement is legal and binding and will remain in effect for this procedure and all future follow-ups conducted by Beauty Shots LLC, and any of their associates. I fully understand the risks and side effects associated with the treatment. I freely assume these risks and release Beauty Shots LLC, and any of their associates of all liability.

HIPAA Authorization and Acknowledgement for Open Setting Communication

As a concierge medical spa operating in a home-based setting, we strive to provide a welcoming and comfortable atmosphere. Due to the nature of our space, some discussions regarding health, wellness, and treatment goals may occur in a shared or open area where others may be present.

To comply with the health insurance portability and accountability act of 1996 (HIPAA), and to respect you right to privacy, we ask you to review and acknowledge the following:

Acknowledgement of an open setting environment

I understand that:

- Consultations or conversations regarding weight goals, health history, treatment plans, vitamin injections, prescription therapies, IV therapy, toxin , and dermal filler may take place in an open area.

- Although reasonable efforts will be made to maintain confidentiality, there is a possibility that other clients or individuals may overhear portions of these conversations.

- I am not required to have any personal health discussions in an open setting.

Client Rights

- I understand that I may change my preference at any time by informing a staff member.

- I understand that my choice will not affect my care or access to services in any way.

PHOTO AND VIDEO RELEASE FORM

I grant the right to capture, modify, edit, reproduce, exhibit, publish, distribute, and utilize any photographs, videos, and/or audio recordings taken of me for lawful promotional purposes. These materials may include, but are not limited to, newspapers, flyers, posters, brochures, advertisements, press kits, websites, social media platforms, and other forms of print and digital communication. I provide this authorization without expecting any payment or other forms of consideration.

This authorization remains in effect indefinitely and applies to all languages, media, formats, and markets, whether currently known or discovered in the future.

I willingly waive any rights to royalties or other compensation arising from or related to the use of these photographs or recordings.

I acknowledge and accept that the materials created through this agreement will be the property of Beauty Shots LLC and will not be returned to me.

I hereby release and discharge Beauty Shots LLC from any liability, claims, or legal actions that may arise, including those made by myself, my heirs, representatives, executors, administrators, or any other individuals acting on my behalf or on behalf of my estate.

By signing below, I confirm that I have thoroughly read and comprehended the entirety of the release agreement stated above.

By signing below, I hereby acknowledge that I have completely read and fully understand the above release agreement

Please select one of the following;*

I authorize Beauty Shots LLC to discuss my goals, treatment, and services in an open setting where others may be present.I do NOT authorize Beauty Shots LLC to discuss my goals, treatment, and services in an open setting where others may be present.

Client Signature*

Photo and Video release consent

Provider Signature*

Date*

Date