Injection Form

Client Information
Full Name:
Date of Birth:

MonthDayYear
Date
Phone Number:
Email Address:
example@example.com
Emergency Contact Name & Phone:
Allergies / Medical Conditions:
Services Requested
Please check all that apply and read the brief description of each service:

Injectables - Includes neurotoxins and dermal fillers. Used for facial rejuvenation, smoothing fine lines, wrinkles, and enhancing facial contours. Possible side effects include bruising, swelling, redness, or temporary discomfort.Neurotoxins (e.g., Botox, Dysport) - Used to relax targeted muscles to reduce the appearance of wrinkles. Effects typically last 3-6 months. Risks may include mild bruising, temporary drooping, or asymmetry.Dermal Fillers (e.g., Juvederm, Restylane) - Injectable gels to restore volume, contour lips, cheeks, and other areas of the face. Results are temporary and may last 6-18 months depending on product and area treated. Risks include bruising, swelling, infection, or uneven results.IV Hydration Therapy - Intravenous infusion of fluids, vitamins, and minerals to rehydrate, boost energy, or improve wellness. Benefits may include improved hydration, nutrient

replenishment, and overall wellness support. Risks include vein irritation, bruising, or rare allergic reactions.
Weight Loss Therapy - May include FDA-approved medications, nutritional guidance, and lifestyle support to aid in weight management. Results vary by individual, and therapy requires adherence to a provider-recommended plan. Potential side effects depend on the medication used and individual health conditions.
Consent & Acknowledgment
I, the undersigned, acknowledge and agree to the following:
1. I understand that the treatments I am receiving involve potential risks and side effects.
2. I have disclosed all relevant medical conditions, medications, and allergies to the provider.
3. I understand that results may vary and are not guaranteed.
4. I acknowledge that this clinic is nurse-owned and operated under the supervision of a licensed medical director.
5. I have had the opportunity to ask questions about the procedures and have received satisfactory answers.
6. I consent to receive the selected treatments and understand that I can withdraw consent at any time.
7. I consent to the collection, use, and storage of my personal health information in accordance with HIPAA regulations.
Post-Treatment Instructions
I acknowledge that I have received and understand post-treatment instructions for the services provided.
Signature
Digital Signature:
Date:

MonthDayYear
Date
Printed Name