Client Model Waiver Form for Cosmetic Injectables & Training
Please review and complete the waiver to participate in in-clinic procedures and advanced training sessions.
Participant Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What Cosmetic Treatments and Services are you Interested with?
*
Botox/ Dysport
Dermal Fillers
PRP/PRF/Naturagel
Biostimulators ( Sculptra/Radiesse)
Skin and Hair Treatments ( Microneedlings, Skin Boosters, Hair Prp/exosomes)
Skin Laser or RF or Laser Hair Removal
Do you have any allergies (especially to medications or anesthetics)?
*
No
Yes (please specify below)
If yes, please list your allergies
Please list any current medications you are taking as maintenance or supplements
Do you have any relevant medical conditions (e.g., bleeding disorders, autoimmune diseases, pregnancy, breastfeeding)?
*
No
Yes (please specify below)
If yes, please specify your medical conditions
I understand that all procedures will be performed by licensed healthcare professionals (nurses and/or/physicians) under direct supervision of an Experienced Aesthetic Injector, practicing under medical delegation in compliance with Canadian Regulations. Please Type YES if u understand.
I hereby consent to being photographed and/or recorded during the training and demo or content creation session for social media, educational and marketing purposes. Images and Videos may be used as an Internal Educational Content for Invicta Academy and approved affiliates for teaching, supervision and competency training. Please Type YES if you give your consent.
As a model client, I understand that the treatment fees are at a reduced price cost to reflect educational nature of the procedure. All Injectables are Health Canada Approved products as well as the Machines and Equipment to be used. While all effort will to be made to ensure safety and aesthetic results, individual results vary. No refunds are provided once treatment or service is administered. Please Type YES if you understand and agree.
Do you want to be add to our Client Model List for optimum access to all our in clinic model client opportunities? Type Yes to be added.
Signature (Please sign below to confirm your consent and waiver)
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
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