• Consultation form

    For other services (not for Lash Extensions))
  •  -
  • When you book your service on our website (book now button) please use the search option at the top for your service. Make sure to book Waxing and Sugaring correctly as they are different services. 

  •  

    If doing a Sugaring session (hair removal) your hair needs to be a quarter of an inch long. (Usually 3 to 4 weeks depending on hair growth for each guest) for waxing services (the hair can be a little shorter) please book sugar or wax depending on hair growth.

  • Please make sure to read the prep and care instructions on the appointment page of our website, Before agreeing to the terms and submitting this form. 

     

    If you are a model please keep in mind you are agreeing to be serviced by a technician in training and results may vary for your service. 

     

     

  • For Botox/ Fillers please click next to complete additional forms, otherwise click submit.

  • These remaining forms are for Botox/ fillers only

    Please select submit on previous page if you are not interested in Botox/ Fillers.
  •  -  -
    Pick a Date
  • I understand the information on this form is essential to determine my medical and cosmetic needs and the provision of treatment. I understand that if any changes occur in my medical health/history, I will report it to he provider as soon as possible. I have read and understand the above medical questionnaire. I acknowledge that all answers have been recorded truthfully and I will not hold any staff member of Sweet Angel Studio or the provider responsible for any errors or omissions that I have made in the completion of this form.

  • Clear
  • The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives of the procedure named above. This material serves as a supplement to the discussion you have with your doctor/healthcare provider. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing the consent form.

    THE TREATMENT
    Botulinum toxin (Botox® and similar agents) is a neurotoxin produced by the bacterium Clostridium A. Botulinum toxin can relax the muscles on areas of the face and neck which cause wrinkles associated with facial expressions or facial pain. Treatment with botulinum toxin can cause your facial expression lines or wrinkles to be less noticeable or essentially disappear. Areas most frequently treated are: a) glabellar area of frown lines, located between the eyes; b) crow’s feet (lateral areas of the eyes); c) forehead wrinkles; d) radial lip lines (smokers lines), e) head and neck muscles. Botox is diluted to a very controlled solution and when injected into the muscles with a very thin needle, it is almost painless. Patients may feel a slight burning sensation while the solution is being injected. The procedure takes about 15-20 minutes and the results can last up to 3 months. With repeated treatments, the results may tend to last longer. For reasons not understood, some patients may be less sensitive or resistant to the effects of Botox. In these patients, the treatment may not be as effective or last as long as would ordinarily be expected. Some patients may be REQUIRED to have touch up doses.

  • RISKS AND COMPLICATIONS
    Before undergoing this procedure, understanding the risks is essential. No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalization, and/or extended outpatient therapy to permit adequate treatment. It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure and in this specific instance such risks include but are not limited to: 1.Post treatment discomfort, swelling, redness, and bruising, 2. Double vision, 3. A weakened tear duct, 4. Post treatment bacterial, and/or fungal infection requiring further treatment, 5. Allergic reaction, 6. Minor temporary droop of eyelid(s) in approximately 2% of injections, this usually lasts 2-3 weeks, 7. Occasional numbness of the forehead lasting up to 2-3 weeks, 8. Transient headache and 9. Flu-like symptoms may occur.

  • PREGNANCY, ALLERGIES & NEUROLOGIC DISEASE

    I am not aware that I am pregnant and I am not trying to get pregnant, I am not lactating (nursing). I do not have any significant neurologic disease including but not limited to myasthenis gravis, multiple sclerosis, lambert-eaton syndrome, amyotrophic lateral sclerosis (ALS), and parkinson’s. I do not have any allergies to the toxin ingredients, or to human albumin. 

    ALTERNATIVE PROCEDURES
    Alternatives to the procedures and options that I have volunteered for are understood. Alternatives include but are not limited to no treatment, chemical peels, topical creams, laser resurfacing, and other modalities.

  • RIGHT TO DISCONTINUE TREATMENT

    I understand that I have the right to discontinue treatment at any time

    I hereby indemnify the Provider from any liability relating to the procedures that I have volunteered for. I also understand that any treatment performed is between me and the doctor/healthcare provider who is treating me and I will direct all post-operative questions or concerns to the treating clinician.  

    I hereby indemnify the facility/ room where this treatment is being performed from any liability relating to the procedures that I have volunteered for

     

    PUBLICITY MATERIALS

    I authorize the taking of clinical photographs and videos and their use for scientific and marketing purposes both in publications and presentations. I understand that photographs and video may be taken of me for educational and marketing purposes. I hold the treating provider harmless for any liability resulting from this production. I waive my rights to any royalties, fees and to inspect the finished production as well as advertising materials in conjunction with these photographs. 


    RESULTS
    I am aware that when small amounts of purified botulinum toxin are injected into a muscle it causes weakness or paralysis of that muscle. This appears in 2 – 10 days and usually lasts up to 3 months but can be shorter or longer. In a very small number of individuals, the injection does not work as satisfactorily or for as long as usual and there are some individuals who do not respond at all. I understand that I will not be able to use the muscles injected as before while the injection is effective but that this will reverse after a period of months at which time re- treatment is appropriate. I understand that I must stay in the erect posture and that I must not manipulate the area (s) of the injections for the 4 hours post-injection period.

    I understand this is an elective procedure and I hereby voluntarily consent to treatment with botulinum toxin injections for facial dynamic wrinkles, TMJ dysfunction, bruxism and types of orofacial pain including headaches and migraines. The procedure has been fully explained to me. I also understand that any treatment performed is between me and the healthcare provider who is treating me and I will direct all post-operative questions or concerns to the treating clinician. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure and I understand that no guarantees are implied as to the outcome of the procedure. I also certify that if I have any changes in my medical history I will notify the doctor/healthcare professional who treated me immediately. I also state that I read and write in English.

    ______________________________________________________________________________​

  • Clear
  • INFORMED CONSENT FOR DERMAL FILLER TREATMENT

    Please Read treatment, risks and policy/ procedures for fillers
  • The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives of the procedure named above. This material serves as a supplement to the discussion you have with your doctor/healthcare provider. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing the consent form.

    THE TREATMENT
    Treatment with dermal fillers (Juvederm products) can smooth out facial folds and wrinkles, add volume to the lips, and contour facial features that have lost their volume and fullness due to aging, sun exposure, illness, etc.  Facial rejuvenation can be carried out with minimal complications.  These dermal fillers are injected under the skin with avery fine needle.  This produces natural appearing volume under wrinkles and folds which are lifted up and smoothed out.  The results can often be seen immediately.  Initial ____

    RISKS AND COMPLICATIONS
    Before undergoing this procedure, understanding the risks is essential. No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list.  Some of these risks, if they occur, may necessitate hospitalization, and/or extended outpatient therapy to permit adequate treatment. It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure and in this specific instance such risks include but are not limited to:  1) Post treatment discomfort, swelling, redness, bruising, and discoloration; 2) Post treatment infection associated with any transcutaneous injection;  3) Allergic reaction; 4) Reactivation of herpes (cold sores); 5) Lumpiness, visible yellow or white patches; 6) Granuloma formation; 7) Localized necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occurs.  Initial ____

    PREGNANCY AND ALLERGIES

    I am not aware that I am pregnant.  I am not trying to get pregnant.  I am not lactating (nursing). I do not have or have not had any major illnesses which would prohibit me from receiving dermal fillers.  I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to lidocaine. Initial ____

    ALTERNATIVE PROCEDURES
    Alternatives to the procedures and options that I have volunteered for have been fully explained to me. Initial ____

    PAYMENT

    I understand that this is an "elective” procedure and that payment is my responsibility and is expected at the time of treatment. Initial ____

    RIGHT TO DISCONTINUE TREATMENT

    I understand that I have the right to discontinue treatment at any time. Initial ____

    I hereby indemnify the Provider from any liability relating to the procedures that I have volunteered for. I also understand that any treatment performed is between me and the doctor/healthcare provider who is treating me and I will direct all post-operative questions or concerns to the treating clinician.  Initial____

    I hereby indemnify the facility/ room where this treatment is being performed from any liability relating to the procedures that I have volunteered for. Initial____

    PUBLICITY MATERIALS

    I authorize the taking of clinical photographs and videos and their use for scientific and marketing purposes both in publications and presentations. I understand that photographs and video may be taken of me for educational and marketing purposes. I hold the provider harmless for any liability resulting from this production. I waive my rights to any royalties, fees and to inspect the finished production as well as advertising materials in conjunction with these photographs.

    Initial ____

     

    RESULTS
    Dermal fillers have been shown to be safe and effective when compared to collagen skin implants and related products to fill in wrinkles, lines and folds in the skin on the face.  Its effect can last up to 6 months or longer.  Most patients are pleased with the results of dermal fillers use. However, like any esthetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that wrinkles and folds will disappear completely, or that you will not require additional treatment to achieve the results you seek. The dermal filler procedure is temporary and additional treatments will be required periodically, generally within 4-6 months, involving additional injections for the effect to continue.  I am aware that follow-up treatments will be needed to maintain the full effects.  I am aware the duration of treatment is dependent on many factors including but not limited to:  age, sex, tissue conditions, my general health and life style conditions, and sun exposure.  The correction, depending on these factors, may last up to 6 months and in some cases shorter and some cases longer.  I have been instructed in and understand the post-treatment instructions.  Initial ____

    I understand this is an elective procedure and I hereby voluntarily consent to treatment with dermal fillers for facial rejuvenation, lip enhancement, establish proper lip and smile lines, and replacing facial volume.  The procedure has been fully explained to me. I also understand that any treatment performed is between me and the healthcare provider who is treating me and I will direct all post-operative questions or concerns to the treating clinician. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure and I understand that no guarantees are implied as to the outcome of the procedure. I also certify that if I have any changes in my medical history, I will notify the healthcare professional who treated me immediately. I also state that I read and write in English.

  • Clear
  • HIPPA COMPLIANCE PATIENT CONSENT FORM

    Please read and sign at bottom
  • Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

    The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

    The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

    You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

    By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

    By signing this form, I understand that:

    · Protected health information may be disclosed or used for treatment, payment, or healthcare operations.

    · The practice reserves the right to change the privacy policy as allowed by law.

    · The practice has the right to restrict the use of the information, but the practice does not have to agree to those

    restrictions.

    · The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.

    · The practice may condition receipt of treatment upon execution of this consent.

    By signing this form, you are consenting for us to phone, email, or send a text to you to confirm appointments. We may leave a message on your answering machine on the phone number given to provider.

     

  • Clear
  • Bruise Prevention Protocol

    Please read these instructions to prepare for your treatment
  • Please follow these recommendations to minimize the risk of bruising and swelling from injections of Botox, Juvéderm or Voluma.

    One week before your treatment:

    Avoid taking aspirin or NSAIDs (such as ibuprofen, Advil, Motrin, Aleve), Vitamin E supplements, Omega 3 supplements, turmeric supplements and Ginkgo biloba supplements. Tylenol is fine. You can resume these medications and supplements 24 hours after your injection. If you have any questions or medical concerns, consult your physician prior to stopping any medication or supplement.

    One day before your treatment (recommended if treating with dermal fillers):

    Begin taking an Arnica Montana supplement, and continue for 4 to 6 days after the injection. Arnica Montana is a homeopathic remedy that may help reduce swelling and bruising. It can be purchased at most health food stores, vitamin stores and major pharmacies. Follow the instructions on the supplement container. If you have a medical condition that has an increased risk of blood clots, or if you are using a mediation to prevent blood clots, please contact your physician before using Arnica.

    Immediately following your treatment:

    If you have swelling from an injection of Juvéderm or Voluma, you can apply cold compresses (such as frozen peas wrapped in a towel) to the area to reduce swelling and discomfort.

    If you bruise, beginning 24 hours after your treatment:

    Apply Arnica gel or cream to the bruised area and gently massage it into the skin 3 times daily. Arnica cream or gel can be purchased at most health food stores.
    Eat fresh pineapple daily. The Bromelain in pineapple may help the body naturally eliminate the bruise.

    If you have soreness or swelling, you may take aspirin or ibuprofen as directed on the container.
    You may cover the bruised area with makeup. We find that concealers and mineral foundations (or mineral foundation layered over concealer) work well, but may need to be applied several times a day until the bruise resolves. Note that gold/yellow tones help neutralize the purple tones in a bruise.

    Bruising is infrequent, but sometimes occurs following an injection of Botox. Minor bruising and minor swelling is more common following injections of Juvéderm or Voluma. Sometimes bruising or swelling arise a day or two after the injection. The treated area may also be tender for a few days, and bruises often look a little deeper in color as they heal. This is normal. However, if these symptoms persist for more than a few days or get worse (increasingly tender, red or swollen) instead of getting better, contact your provider immediately at (360) 353-1537

     

    Recommended Pre & Post Care for Botox Cosmetic®

    For best results please follow these instructions.

    Before your treatment:

    • Review the Bruise Prevention Protocol.
    • Some medications or supplements that thin the blood may increase the risk of
    bruising. Consult with your physician.

    • Avoid facials and chemical peels for 1-2 days prior to treatment and 1-2 days after
    treatment.

    • Notify your physician of any changes to your health history or medications since your
    last appointment.

    • If you have a history of herpes or cold sores, an anti-viral prescription is
    recommended prior to treatment in that area.

    After your treatment:

    • Avoid strenuous exercise, extensive sun or heat, and alcohol for 24 hours following
    treatment.

    • Remain upright for 4 – 6 hours after injection.
    • Don’t massage or manipulate the injection areas. Wash your face gently.
    • You may take Tylenol for discomfort, but wait 24 hours before taking ibuprofen (such
    as Motrin or Advil), aspirin, Aleve or Vitamin E to minimize bruising.

    • If bruising occurs, refer to the Anti-Bruise Protocol above.
    • Severe pain after injection is not usual. In the unlikely event this occurs, call your
    provider immediately.

    • For best results, please schedule your next treatment 12-16 weeks after today’s
    treatment. It is important to maintain a regular injection schedule to optimize your

    results and reduce formation of new wrinkles.

    Recommended Pre & Post Care for Juvéderm® and Voluma®

    For best results please follow these instructions.

    Before your treatment:

    • Review the Bruise Prevention Protocol.
    • Some medications or supplements that thin the blood may increase the risk of
    bruising. Consult with your physician.

    • Avoid facials and chemical peels for 1-2 days prior to treatment and 1-2 days after
    treatment.

    • Notify your physician of any changes to your health history or medications since your
    last appointment.

    • If you have a history of herpes or cold sores, an anti-viral prescription is
    recommended prior to treatment in that area.

    After your treatment:

    • Avoid strenuous exercise, extensive sun or heat, and alcohol for 24 hours following
    treatment.

    • Use cold compresses briefly if the treated area is swollen.
    • Don’t massage or manipulate the injection areas. Wash your face gently.
    • For Voluma injections, avoid sleeping on the injection areas for 1-2 days. If possible,
    sleep on your back or use soft pillows.

    • The most common side effects are redness, swelling, tenderness, firmness, itching,
    lumps/bumps, discoloration, and bruising at the injection sites. These side effects

    should resolve within a week.

    • You may take Tylenol for discomfort, but wait 24 hours before taking ibuprofen (such
    as Motrin or Advil), aspirin, Aleve or Vitamin E to minimize bruising.

    • If bruising occurs, refer to the Anti-Bruise Protocol above.
    • Severe pain after injection is not usual. In the unlikely event this occurs, call your
    Provider immediately.

    • Please schedule a follow up appointment in 2 to 4 weeks following your treatment.
     

    Please sign that the information above has been reviewed and is understood.

    __________________________________________________________________________________________

  • Clear
  • If you are interested in a paper copy of these forms, please ask your Cosmetic Nurse before or after your appointment . 

  •  

    I am the treating healthcare professional.  I discussed the above risks, benefits, and alternatives with the patient. The patient had an opportunity to have all questions answered and was offered a copy of this informed consent.  The patient has been told to contact my office should they have any questions or concerns after this treatment procedure.

    ________________________________________________________________

  •  :
  •  -  -
    Pick a Date
  • Should be Empty:
Jotform Logo
Now create your own JotForm - It's free! Create your own JotForm