Island Aesthetics Mobile Medspa Forms

Island Aesthetics-Client Intake Packet

Please complete prior to appointment
Date*

MonthDayYear
Today’s Date
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Date of birth*

MonthDayYear
Date
What is your age?*
Age
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact (Name/Relationship/Phone)*
Emergency Contact (Name/Relationship/Phone)
Signature*

Medical history questionnaire
Are you currently taking any medications or supplements? If so, please list them
If currently taking medication’s, what medical conditions are you taking them for?
Do you currently have any active skin infections, primarily in the areas which we will be treating?
Have you ever been diagnosed with any autoimmune diseases? If so, please list them
Have you had any surgeries or cosmetic procedures within the past 10 years-particularly involving your face, eyes or neck?
Have you ever had a life-threatening reaction to any medication or to anesthesia (anaphylactic reaction)? If so, please describe the reaction you had, what caused it, and when it occurred.
Are you allergic to lidocaine or cows milk, or any other food or drug?
Do you have any history of HSV (herpes simplex virus)/Fever Blisters?
Have you had any dental procedures in the past two weeks or do you plan to have any in the following two weeks?
When was the last time that you had Botox (or similar neuromodulator) or dermal fillers?

DERMAL FILLER TREATMENT CONSENT

Purpose:

This document provides written information regarding risks, benefits, and alternatives of dermal filler

treatment and supplements discussion with your provider.

The Treatment:

Dermal fillers (including but not limited to Juvederm®, Restylane®, Revanesse®, Radiesse®, and

others) restore volume, smooth wrinkles, and contour features. Injections may be performed using

needles or cannulas.

Expected Results:

Results may be immediate but are not guaranteed. Longevity varies. Additional syringes or treatments

may be necessary.

Risks & Complications:

Common risks include swelling, bruising, redness, itching, tenderness, discoloration, infection,

asymmetry, lumps, migration, delayed inflammatory response, herpes reactivation, granulomas,

nodules, prolonged edema, and scarring.

Rare but serious complications include vascular occlusion causing tissue necrosis, ulceration, nerve

injury, visual disturbance, blindness, stroke, or death. Emergency treatment including hyaluronidase

may be required. Immediate reporting of unusual pain, blanching, or vision changes is critical.

Alternatives:

Alternatives include no treatment, skincare, neurotoxins, energy-based procedures, or surgery.

Pregnancy & Allergies:

Treatment should not be performed if pregnant or nursing. I confirm disclosure of allergies and

conditions.

Payment Responsibility:

Dermal filler treatment is elective. I accept financial responsibility for services rendered.

Aftercare Compliance:

I agree to follow post-treatment instructions and report complications.

Right to Discontinue:

I may decline or discontinue treatment at any time.

Acknowledgment:

I confirm risks, benefits, and alternatives were explained and voluntarily consent to treatment.
Yes-I consent to clinical photographyNo- I do not consent
Patient Signature- Dermal Filler Consent*
Date Signed

MonthDayYear
Date

Neurotoxin Treatment Consent
Multi-Brand Botulinum Toxin Informed Consent

Treatment Description:

I consent to cosmetic treatment using botulinum toxin type A injections intended to temporarily relax

targeted muscles and reduce wrinkles. Products that may be used include Botox®, Dysport®,

Xeomin®, Jeuveau®, and/or Daxxify®. The specific product will be determined by the provider based

on clinical judgment.

Expected Results & Duration:

Results generally begin within 2–14 days. Traditional neurotoxins typically last 3–4 months; Daxxify

may last up to 6 months or longer. More than one treatment may be necessary to achieve desired

results. No guarantees have been made regarding outcome.

Medical History Acknowledgment:

I confirm I have completed a medical history form and disclosed medications, supplements, allergies,

and conditions. I agree to notify my provider of any changes prior to treatment.

Risks & Possible Side Effects:

Potential risks include but are not limited to: swelling, bruising, redness, rash, infection, scarring,

headache, pain at injection site, numbness, flu-like symptoms, asymmetry, spread of toxin effect,

drooping eyelid or brow, double vision, corneal exposure due to reduced blinking, ulcerations,

respiratory symptoms, dizziness, or uneven muscle response. Side effects are typically temporary but

may persist weeks or longer.

Contraindications:

Botulinum toxin should not be administered during pregnancy or nursing. I confirm I have disclosed

neuromuscular disorders, allergies, or infections at treatment sites.

Units & Dosing Acknowledgment:

The number of units injected represents an estimate determined by clinical evaluation. Adjustments oradditional treatments may be required. I understand there is no guarantee of results.

Financial Responsibility:

I agree to pay for services rendered and understand additional treatments may incur additional cost. I

accept responsibility for collection costs or legal fees in cases of non-payment.

Aftercare Compliance:

I agree to follow all aftercare instructions provided by my injector to support optimal results.

Liability Acknowledgment:

I have read and understand this consent and voluntarily consent to treatment. I release the provider

and facility from liability associated with this procedure to the extent permitted by law.
Yes- I consent to clinical photographyNo- I Do Not Consent
Aftercare Instructions:
I understand that I will receive verbal and/or written aftercare instructions specific to my treatment. I agree to follow these instructions to support optimal results and reduce the risk of complications.

Follow-Up Communication:
Results from neurotoxin treatments develop over 7–14 days. Dermal filler results may evolve as swelling resolves.

I understand that I may send a selfie check-in message to my provider approximately 10–14 days after treatment if I have questions or would like evaluation of results. Suggested photos include:
• Front relaxed
• Full smile
• Brows raised (for neurotoxin)
• Treated area close-up (if applicable)

These images are for clinical communication only and do not replace an in-person medical evaluation if concerns arise.

I agree to contact my provider promptly if I experience unusual pain, blanching, prolonged swelling, visual changes, or other concerning symptoms.
Patient Signature*
Date*

MonthDayYear
Date

PRE-TREATMENT REMINDERS

• Avoid NSAIDs (ibuprofen, aspirin) 24–48 hrs prior if possible
• Avoid alcohol 24 hrs prior if possible
• Treatment cannot be performed if pregnant, breastfeeding, or if you have an active skin infection in the treatment area
• For filler: discuss recent dental work prior to treatment
• Lip filler may trigger a cold sore if you have a history of HSV-1; Island Aesthetics does not prescribe antivirals

NEUROTOXIN AFTERCARE

• Remain upright 4 hrs
• No rubbing/massage
• No pressure 6 hrs (hats/headbands, face on hands/arms)
• No strenuous exercise today
• Avoid NSAIDs today

2 weeks: Send a selfie making expression for assessment.

FILLER AFTERCARE

• Swelling, tenderness, or bruising can be normal
• No strenuous exercise 24 hrs
• Avoid alcohol today
• Avoid NSAIDs today
• Do not massage unless instructed
• Sleep slightly elevated
• Hydrate

Seek immediate medical attention and contact Island Aesthetics for severe pain, blanching, or unusual discoloration.
I Agree
Should be Empty:

Island Aesthetics-Client Intake Packet

Medical history questionnaire

Neurotoxin Treatment Consent