Refresher Aesthetic Consent

Returning Client for Aesthetics
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date

MonthDayYear
Date
No changes in my medical historyNo new neurological conditionsNo new autoimmune conditionsNo recent infections or illnessNo new medicaitons that affect bleeding (aspirin, NSAIDs, blood thinners)Not pregnant, trying to conceive (including fertility treatments) or breastfeedingAny other information ______________________________________________________________
If any changes occurred, please describe: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Review of Known Risks
I understand that neuromodulators, fillers and biostimulators such as Botox, Juveau, Evolysse, Dysport, Restylane, Sculptra and more may cause temporary side effects including:
- Bruising
- Swelling
- Headache
- Tenderness
- Asymmetiry
- Eyelid or brow drooping (ptosis)
- Dry eye or tearing
- Difficulty with certain facial expressions
- Lumps or firmness
- Delayed inflammatory reaction
- Infection
- Rare allergic reaction
- Rare but serious vascular occulsion, tissue injury or vision changes
I understand that no guarantees have been made regarding the outcome or longevity of results.

I acknowledge that individual repsonses vary and that unforseen or previously undocumented risks may occur. I accept the possiblity of known and unknown complications.
No Guarantee of Results
I acknowledge:
- No guarantee has been made regarding the degree or duration of improvement.
- Touch-ups may be required.
- Results depend on muscle strength, metabolism, other unknown factors and individual response.
Post Treatment Agreement
I agree to:
- Avoid excessive pressure or massage unless directed.
- Avoid strenous exercise of activity for 24 hours.
- Keep my head upright for 4 hours after the procedure.
- Avoid heat exposure (sauna, hot tubs, steam from shower, direct sun, etc) for the first 48 hours.
- Avoid additonal aesthetic treatments for at least two weeks (unless cleared by your provider).
- Follow any and all post treatment instructions given verbally and/or written.
- Contact the office immediately for unusual pain, discoloration, vision changes or other concerns.
Acknowledgement

I have had the opportunity to ask questions and I understand the risks, benefits and alternatives. I agree to be financially responsible for treatments and I agree to follow all pre and post treatment instructions.
Signature

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Returning Client for Aesthetics

Review of Known Risks

No Guarantee of Results

Post Treatment Agreement

Acknowledgement