SIGNATURE PAGE
Consent for treatment
I understand that I am receiving an intramuscular or intravenous injection as a part of a wellness treatment. These injections may include a combination of steroids, vitamins, amino acids, antioxidants, or supportive nutrients. I have been informed of the potential benefits including improved energy, metabolism, immune support, and beauty enhancement. I understand that the side effects are rare but may include injection site discomfort, allergic reaction, or dizziness. I understand this treatment is elective and I consent to proceed under the supervision of a licensed medical provider.
Informed Consent for Injection
This service includes an injection of dexamethasone (a corticosteroid), Triamcinolone, Vitamin B12, lidocaine, and may include the optional add-in of toradol to reduce inflammation, improve energy, and provide local pain relief.
Potential benefits: reduced pain, swelling and inflammation, improved function and mobility.
Potential risks: infection, bleeding, local site reaction, allergic response, temporary flushing, elevated blood pressure, insomnia, mood changes, or increased blood sugar levels. Long term or repeated use of corticosteroids may contribute to bone thinning or suppression of adrenal gland.
I understand this treatment is elective and medically supervised. I consent to receive the Angel Kiss injection.
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.