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Dr. Edmund Fisher Inc dba Lüz Lounge

 

 

 

Hyaluronic Filler Informed Consent 

Dr. Edmund Fisher dba Lüz Lounge

The Hyaluronic Acid fillers mentioned above are sterile gels consisting of non-animal stabilized hyaluronic acid for injection into the skin to correct facial lines, wrinkles and folds in the United States. In addition to these indications, Hyaluronic Acid has been used to enhance the appearance & fullness of lips in over 60 other countries.  

My practitioner has explained the use of & indication for the Hyaluronic Acid fillers to me. I have had the opportunity to have all questions answered to my satisfaction. I have been specifically informed of the following: after the injection some common injection-related reactions might occur, such as swelling, redness, pain, itching, bruising, skin discoloration and tenderness at the implant sight. They typically resolve spontaneously within 2-3 days after injection into the skin and within a week after injection into the lips. Other types of reactions are very rare, but about 1 in 5,000 treated patients have experienced localized reactions thought to be of a hypersensitivity nature. These have usually consisted of swelling at the implant site, sometimes affecting the surrounding tissues. Redness, tenderness, and rarely acne-like formations have also been reported. The onset of these reactions has occurred one to several weeks after the initial treatment. The average duration of the effect is 2 weeks. Severe reactions are rarely reported including vascular occlusion which may result in scarring and blindness

My practitioner has also informed me that, depending on the area treated, skin type, and the injection technique, the effect of a treatment can last 6 months or even longer. (Lips: approximately 4-6 months), but that in some cases the duration of the effect can be shorter or even longer. Touchup and follow-up treatments help sustain the desired degree of correction. 

I am requesting Hyaluronic Acid to be used for cosmetic facial augmentation. This filler is a nonanimal stabilized hyaluronic acid gel substance. Hyaluronic acid is an important structural element in human skin and tissue. It acts by adding volume to the tissue, shaping the contours of the face, correcting folds and enhancing the lips. The type of filler you will need is determined by the corrections you wish to make to your face.  

As with any medical procedure, you should be aware of the safety issues and restrictions associated with this treatment.  

With any injection procedure there are risks of infections, lumpiness, redness, swelling, pain, itching, discoloration or tenderness at the implant site. Typically resolution occurs within 2-3 days after the injection.  

Hypersensitivity has been reported in 1 in 5000 treated patients. This consists of excessive swelling and firmness and is usually self resolved in about two weeks.  

If I choose to have topical anesthesia applied I understand all risk associated with topical anesthesia are possible including allergic reaction, swelling, irritation, and in large quantities overdose which can result in death. 

I will not drink alcohol for 24 hours after injection. 

I understand I cannot have any dental procedures, including routine cleanings, for two weeks prior and two weeks after injectable filler treatment.  

I understand the common, expected adverse effects: needle marks, bruising, redness, swelling, acute severe lip swelling, transient lumpiness and asymmetry. 

I understand that there is a risk of hypersensitivity reaction , vascular occlusion, epidermal necrosis, blindness, infarction, or embolic phenomena.  

I will notify my physician immediately if there is ongoing or worrisome red or purple discoloration, tingling, or burning sensation.  

I will not expose the treated area to heat, such as sunbathing or tanning booths. I may be dissatisfied with the results.  

I should not receive this treatment if I have unattainable expectations. I understand that multiple treatments may be necessary to achieve desired results. Touch up treatments may be necessary to maintain desired results. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. Clinical results will vary per patient. No refunds will be given for treatments received. I understand that any rescheduling must be done 72 hours before my treatment. 

I understand that the use of the fillers may be use "off label" from the FDA cleared uses, based on the practitioners discretion and to achieve aesthetic goals. 

By signing the consent, I also consent to the use of hyaluronidase, an enzyme that breaks down filler which is to be used in case of emergencies such as vascular occlusion or blindness. I understand that there will be loss of volume and there can be some skin laxity which in itself may not provide a good aesthetic result. Although some of the effects can be immediate, I understand it can take up to 24-48 hours for reversal to be seen and the treatment may need to be repeated.

What are the possible side effects of hyaluronidase? Allergic reactions: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Less serious side effects may include pain, itching, redness, or swelling where the medication was injected. This is not a complete list of side effects and others may occur.


I understand and agree that all services rendered to me are charged to me directly and that I am personally responsible for payment. I am not pregnant or trying to become pregnant nor am I nursing at this time. The nature and purpose of the treatment have been explained to me. I have read and understand this agreement in its entirety. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment. 

I release the medical staff, from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns. 

 

I authorize Luz Aesthetics to take photos and/or video for sole purpose of education with marketing materials on our website, social media.  All photos and videos are kept in patients file with a HIPPA compliant database only accessible to Luz Aesthetics staff. I understand I not be reimbursed for usage. I understand and agree that these materials shall become the property of Luz Aesthetics’s and will not be returned. If you do not agree to photos for marketing but consent to photographs for documentation purposes only please type XX 

April 21, 2024

 

I understand I’m getting consulted and treated by Dr. Edmund Fisher’s Nurse Practitioners and Registered Nurses today

April 21, 2024

I consent to being treated with the Hyaluronic Acid fillers and I agree with and understand the statements detailed above

 

April 21, 2024 

 

 

CALIFORNIA MEDICAL SERVICES CONTRACT 

All Medical treatments are performed by Edumund Fisher Inc. dba Lüz Lounge

A signed copy of this document is to be emailed/given to the client upon request. Original is to be filed in Client’s medical records. Arbitration Agreement California CD0501Y8v2

ARTICLE I: ARBITRATION Article 1.1: Agreement To Arbitrate: It is understood that any dispute as to medical malpractice by Client, including any party that would have standing to assert a claim on behalf of or in connection with services provided to Client, that is as to whether medical services rendered under this contract were unnecessary, unauthorized or lacking informed consent or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. For purposes of this agreement, “Dispute” means any claim or controversy of whatever kind or nature including (without limitation) any claim or controversy regarding the formation, validity, interpretation and/or enforceability of this agreement to arbitrate and any claim or controversy by the Client asserting loss of consortium, wrongful death, emotional distress or punitive damages. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Article 1.2: Procedure For Initiating Arbitration: Either party to this agreement may initiate Arbitration by submitting a Demand for Arbitration in writing to the other. The Demand shall contain a plain and simple statement of the nature of the Dispute and the remedy demanded. There shall be one Arbitrator who shall be a retired Judge of a court of record. The Arbitrator shall be selected by agreement of the parties on or before 30-calendar days of the date that the Demand for arbitration is deposited for delivery with a common carrier (as determined by a postmark or other equivalent writing imprinted by the common carrier). If the parties have not agreed to a selection of the Arbitrator, than either party may petition the appropriate Superior Court to appoint the Arbitrator and, consistent with CCP § 1281.6, the Superior Court shall appoint the Arbitrator, who shall have the qualifications stated in this paragraph. Article 1.3: Law Governing Arbitration; Arbitrator’s Award And Enforcement. Without reference to its choice of law rules, the Arbitrator shall apply the substantive law of California. The Arbitrator shall render his or her award in writing and the award shall separately state the Arbitrator’s findings of fact and conclusions of law. The Arbitrator’s award shall be binding on the parties to the arbitration and judgment on the award may be entered by a court of competent jurisdiction in California. Judicial proceedings to confirm, amend, or vacate the arbitration award shall also take place in California. To the extent permitted by law, venue for such proceedings shall be in the county (or the federal judicial district) where the services were rendered. Unless the Arbitrator shall determine otherwise, the Arbitration shall take place in the county where the services were rendered. The Arbitrator shall have the authority to hear any claim and award any remedy that could otherwise be heard or rendered by the Superior Court of California or a federal district court in California. Discovery shall proceed in accordance with California Code of Civil Procedure, §§ 1283.1, 1282.05, and, in addition, any party, may, of right, bring a motion for summary judgment or adjudication in accordance with CCP § 437c. The parties to this agreement agree to arbitrate in one proceeding all claims arising out of the same or a related incident, transaction or occurrence. Article 1.4: Small Claims Court: Notwithstanding the foregoing any party to this agreement may initiate and prosecute in the small claims division of the Superior Court any claim at law demanding an amount equal to or less than the jurisdictional limit of the small claims division. Notwithstanding applicable law, no judgment in an action initiated in the small claims division may be entered for an amount in excess of the jurisdictional limit of the small claims division. Article 1.5: Severability: If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provisions. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY MUTUAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO JURY OR COURT TRIAL. 

I have read and agree to the terms/conditions listed in this agreement and understand that I have the right to receive a copy of this arbitration agreement upon request.

 April 21, 2024

 


First Patient's Name

First Name*

Middle Name

Last Name*
First Patient's Date of Birth*
First Patient's Information

Please list all medical conditions, past and present. Are you currently under the care of a doctor/specialist?

Are you currently on any medications? (prescription, herbal supplements, and/or vitamins?) If "yes" please list all medications, dosage and reason for taking

Do you have a history of any autoimmune disorders or a history of oral cold sores? Please list otherwise leave blank.
I agree I am NOT taking any of the following ACE Inhibitors (heart medication): Benazepril (Lotensin), Captopril (Capoten), Enalapril/Enalaprilat (Vasotec oral and injectable), Fosinopril (Monopril), Lisinopril (Zestril and Prinivil), Moexipril (Univasc), Perindopril (Aceon), Quinapril (Accupril), Ramipril (Altace), and Trandolapril (Mavik).*
I agree, I am not taking one of the above medications
I disagree, I am taking one of these medications

Please list any allergies to medications, ingredients or products. If none, type "NONE" *
Have you ever had an adverse/allergic reaction to Hyaluronic Acid filler?*
No
Yes

If yes, please list and describe allergic reaction.
Do you have any allergies to anesthetic? (topical or injectable)*
No
Yes
I am NOT pregnant or breastfeeding*
No, I am not pregnant or breastfeeding.
Yes, I am pregnant or breastfeeding.
I agree that there is a risk of bruising with any injectable treatment and that bruising may last up to two weeks.*
No, I disagree and I do not want to bruise. Unfortunately we cannot guarantee that you wont bruise.
Yes, I agree to the risk.
I'm interested in learning more about.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Coolsculpting (fat reduction and body contouring)
Cortisone injections for cystic acne
Developing a customized 3, 6 or 12 month skin care plan
Eyelash extensions
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Laser Hair Removal
Micro-blading eyebrows
Microdermabrasion
Microneedling
Platelet Rich Plasma (PRP) facial and/or Hair restoration
Red Light therapy/Infrared
Reducing melasma (pregnancy mask)
Reducing rosacea
Removing broken capillaries
Removing brown spots/sun damage
Skin tightening
Tattoo removal
Teeth whitening
Ultherapy or High Intensity Focused Ultrasound (HIFU)
Vitamin B-12 injections

Have you received hyaluronic acid fillers in the past? If so, please list the type, when your last treatment was, and what area(s) were treated. *
First Patient's Signature*
Second Patient's Name

First Name*

Middle Name

Last Name*
Second Patient's Date of Birth*
Second Patient's Information

Please list all medical conditions, past and present. Are you currently under the care of a doctor/specialist?

Are you currently on any medications? (prescription, herbal supplements, and/or vitamins?) If "yes" please list all medications, dosage and reason for taking

Do you have a history of any autoimmune disorders or a history of oral cold sores? Please list otherwise leave blank.
I agree I am NOT taking any of the following ACE Inhibitors (heart medication): Benazepril (Lotensin), Captopril (Capoten), Enalapril/Enalaprilat (Vasotec oral and injectable), Fosinopril (Monopril), Lisinopril (Zestril and Prinivil), Moexipril (Univasc), Perindopril (Aceon), Quinapril (Accupril), Ramipril (Altace), and Trandolapril (Mavik).*
I agree, I am not taking one of the above medications
I disagree, I am taking one of these medications

Please list any allergies to medications, ingredients or products. If none, type "NONE" *
Have you ever had an adverse/allergic reaction to Hyaluronic Acid filler?*
No
Yes

If yes, please list and describe allergic reaction.
Do you have any allergies to anesthetic? (topical or injectable)*
No
Yes
I am NOT pregnant or breastfeeding*
No, I am not pregnant or breastfeeding.
Yes, I am pregnant or breastfeeding.
I agree that there is a risk of bruising with any injectable treatment and that bruising may last up to two weeks.*
No, I disagree and I do not want to bruise. Unfortunately we cannot guarantee that you wont bruise.
Yes, I agree to the risk.
I'm interested in learning more about.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Coolsculpting (fat reduction and body contouring)
Cortisone injections for cystic acne
Developing a customized 3, 6 or 12 month skin care plan
Eyelash extensions
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Laser Hair Removal
Micro-blading eyebrows
Microdermabrasion
Microneedling
Platelet Rich Plasma (PRP) facial and/or Hair restoration
Red Light therapy/Infrared
Reducing melasma (pregnancy mask)
Reducing rosacea
Removing broken capillaries
Removing brown spots/sun damage
Skin tightening
Tattoo removal
Teeth whitening
Ultherapy or High Intensity Focused Ultrasound (HIFU)
Vitamin B-12 injections

Have you received hyaluronic acid fillers in the past? If so, please list the type, when your last treatment was, and what area(s) were treated. *
Third Patient's Name

First Name*

Middle Name

Last Name*
Third Patient's Date of Birth*
Third Patient's Information

Please list all medical conditions, past and present. Are you currently under the care of a doctor/specialist?

Are you currently on any medications? (prescription, herbal supplements, and/or vitamins?) If "yes" please list all medications, dosage and reason for taking

Do you have a history of any autoimmune disorders or a history of oral cold sores? Please list otherwise leave blank.
I agree I am NOT taking any of the following ACE Inhibitors (heart medication): Benazepril (Lotensin), Captopril (Capoten), Enalapril/Enalaprilat (Vasotec oral and injectable), Fosinopril (Monopril), Lisinopril (Zestril and Prinivil), Moexipril (Univasc), Perindopril (Aceon), Quinapril (Accupril), Ramipril (Altace), and Trandolapril (Mavik).*
I agree, I am not taking one of the above medications
I disagree, I am taking one of these medications

Please list any allergies to medications, ingredients or products. If none, type "NONE" *
Have you ever had an adverse/allergic reaction to Hyaluronic Acid filler?*
No
Yes

If yes, please list and describe allergic reaction.
Do you have any allergies to anesthetic? (topical or injectable)*
No
Yes
I am NOT pregnant or breastfeeding*
No, I am not pregnant or breastfeeding.
Yes, I am pregnant or breastfeeding.
I agree that there is a risk of bruising with any injectable treatment and that bruising may last up to two weeks.*
No, I disagree and I do not want to bruise. Unfortunately we cannot guarantee that you wont bruise.
Yes, I agree to the risk.
I'm interested in learning more about.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Coolsculpting (fat reduction and body contouring)
Cortisone injections for cystic acne
Developing a customized 3, 6 or 12 month skin care plan
Eyelash extensions
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Laser Hair Removal
Micro-blading eyebrows
Microdermabrasion
Microneedling
Platelet Rich Plasma (PRP) facial and/or Hair restoration
Red Light therapy/Infrared
Reducing melasma (pregnancy mask)
Reducing rosacea
Removing broken capillaries
Removing brown spots/sun damage
Skin tightening
Tattoo removal
Teeth whitening
Ultherapy or High Intensity Focused Ultrasound (HIFU)
Vitamin B-12 injections

Have you received hyaluronic acid fillers in the past? If so, please list the type, when your last treatment was, and what area(s) were treated. *
Fourth Patient's Name

First Name*

Middle Name

Last Name*
Fourth Patient's Date of Birth*
Fourth Patient's Information

Please list all medical conditions, past and present. Are you currently under the care of a doctor/specialist?

Are you currently on any medications? (prescription, herbal supplements, and/or vitamins?) If "yes" please list all medications, dosage and reason for taking

Do you have a history of any autoimmune disorders or a history of oral cold sores? Please list otherwise leave blank.
I agree I am NOT taking any of the following ACE Inhibitors (heart medication): Benazepril (Lotensin), Captopril (Capoten), Enalapril/Enalaprilat (Vasotec oral and injectable), Fosinopril (Monopril), Lisinopril (Zestril and Prinivil), Moexipril (Univasc), Perindopril (Aceon), Quinapril (Accupril), Ramipril (Altace), and Trandolapril (Mavik).*
I agree, I am not taking one of the above medications
I disagree, I am taking one of these medications

Please list any allergies to medications, ingredients or products. If none, type "NONE" *
Have you ever had an adverse/allergic reaction to Hyaluronic Acid filler?*
No
Yes

If yes, please list and describe allergic reaction.
Do you have any allergies to anesthetic? (topical or injectable)*
No
Yes
I am NOT pregnant or breastfeeding*
No, I am not pregnant or breastfeeding.
Yes, I am pregnant or breastfeeding.
I agree that there is a risk of bruising with any injectable treatment and that bruising may last up to two weeks.*
No, I disagree and I do not want to bruise. Unfortunately we cannot guarantee that you wont bruise.
Yes, I agree to the risk.
I'm interested in learning more about.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Coolsculpting (fat reduction and body contouring)
Cortisone injections for cystic acne
Developing a customized 3, 6 or 12 month skin care plan
Eyelash extensions
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Laser Hair Removal
Micro-blading eyebrows
Microdermabrasion
Microneedling
Platelet Rich Plasma (PRP) facial and/or Hair restoration
Red Light therapy/Infrared
Reducing melasma (pregnancy mask)
Reducing rosacea
Removing broken capillaries
Removing brown spots/sun damage
Skin tightening
Tattoo removal
Teeth whitening
Ultherapy or High Intensity Focused Ultrasound (HIFU)
Vitamin B-12 injections

Have you received hyaluronic acid fillers in the past? If so, please list the type, when your last treatment was, and what area(s) were treated. *
Fifth Patient's Name

First Name*

Middle Name

Last Name*
Fifth Patient's Date of Birth*
Fifth Patient's Information

Please list all medical conditions, past and present. Are you currently under the care of a doctor/specialist?

Are you currently on any medications? (prescription, herbal supplements, and/or vitamins?) If "yes" please list all medications, dosage and reason for taking

Do you have a history of any autoimmune disorders or a history of oral cold sores? Please list otherwise leave blank.
I agree I am NOT taking any of the following ACE Inhibitors (heart medication): Benazepril (Lotensin), Captopril (Capoten), Enalapril/Enalaprilat (Vasotec oral and injectable), Fosinopril (Monopril), Lisinopril (Zestril and Prinivil), Moexipril (Univasc), Perindopril (Aceon), Quinapril (Accupril), Ramipril (Altace), and Trandolapril (Mavik).*
I agree, I am not taking one of the above medications
I disagree, I am taking one of these medications

Please list any allergies to medications, ingredients or products. If none, type "NONE" *
Have you ever had an adverse/allergic reaction to Hyaluronic Acid filler?*
No
Yes

If yes, please list and describe allergic reaction.
Do you have any allergies to anesthetic? (topical or injectable)*
No
Yes
I am NOT pregnant or breastfeeding*
No, I am not pregnant or breastfeeding.
Yes, I am pregnant or breastfeeding.
I agree that there is a risk of bruising with any injectable treatment and that bruising may last up to two weeks.*
No, I disagree and I do not want to bruise. Unfortunately we cannot guarantee that you wont bruise.
Yes, I agree to the risk.
I'm interested in learning more about.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Coolsculpting (fat reduction and body contouring)
Cortisone injections for cystic acne
Developing a customized 3, 6 or 12 month skin care plan
Eyelash extensions
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Laser Hair Removal
Micro-blading eyebrows
Microdermabrasion
Microneedling
Platelet Rich Plasma (PRP) facial and/or Hair restoration
Red Light therapy/Infrared
Reducing melasma (pregnancy mask)
Reducing rosacea
Removing broken capillaries
Removing brown spots/sun damage
Skin tightening
Tattoo removal
Teeth whitening
Ultherapy or High Intensity Focused Ultrasound (HIFU)
Vitamin B-12 injections

Have you received hyaluronic acid fillers in the past? If so, please list the type, when your last treatment was, and what area(s) were treated. *
Sixth Patient's Name

First Name*

Middle Name

Last Name*
Sixth Patient's Date of Birth*
Sixth Patient's Information

Please list all medical conditions, past and present. Are you currently under the care of a doctor/specialist?

Are you currently on any medications? (prescription, herbal supplements, and/or vitamins?) If "yes" please list all medications, dosage and reason for taking

Do you have a history of any autoimmune disorders or a history of oral cold sores? Please list otherwise leave blank.
I agree I am NOT taking any of the following ACE Inhibitors (heart medication): Benazepril (Lotensin), Captopril (Capoten), Enalapril/Enalaprilat (Vasotec oral and injectable), Fosinopril (Monopril), Lisinopril (Zestril and Prinivil), Moexipril (Univasc), Perindopril (Aceon), Quinapril (Accupril), Ramipril (Altace), and Trandolapril (Mavik).*
I agree, I am not taking one of the above medications
I disagree, I am taking one of these medications

Please list any allergies to medications, ingredients or products. If none, type "NONE" *
Have you ever had an adverse/allergic reaction to Hyaluronic Acid filler?*
No
Yes

If yes, please list and describe allergic reaction.
Do you have any allergies to anesthetic? (topical or injectable)*
No
Yes
I am NOT pregnant or breastfeeding*
No, I am not pregnant or breastfeeding.
Yes, I am pregnant or breastfeeding.
I agree that there is a risk of bruising with any injectable treatment and that bruising may last up to two weeks.*
No, I disagree and I do not want to bruise. Unfortunately we cannot guarantee that you wont bruise.
Yes, I agree to the risk.
I'm interested in learning more about.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Coolsculpting (fat reduction and body contouring)
Cortisone injections for cystic acne
Developing a customized 3, 6 or 12 month skin care plan
Eyelash extensions
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Laser Hair Removal
Micro-blading eyebrows
Microdermabrasion
Microneedling
Platelet Rich Plasma (PRP) facial and/or Hair restoration
Red Light therapy/Infrared
Reducing melasma (pregnancy mask)
Reducing rosacea
Removing broken capillaries
Removing brown spots/sun damage
Skin tightening
Tattoo removal
Teeth whitening
Ultherapy or High Intensity Focused Ultrasound (HIFU)
Vitamin B-12 injections

Have you received hyaluronic acid fillers in the past? If so, please list the type, when your last treatment was, and what area(s) were treated. *
Seventh Patient's Name

First Name*

Middle Name

Last Name*
Seventh Patient's Date of Birth*
Seventh Patient's Information

Please list all medical conditions, past and present. Are you currently under the care of a doctor/specialist?

Are you currently on any medications? (prescription, herbal supplements, and/or vitamins?) If "yes" please list all medications, dosage and reason for taking

Do you have a history of any autoimmune disorders or a history of oral cold sores? Please list otherwise leave blank.
I agree I am NOT taking any of the following ACE Inhibitors (heart medication): Benazepril (Lotensin), Captopril (Capoten), Enalapril/Enalaprilat (Vasotec oral and injectable), Fosinopril (Monopril), Lisinopril (Zestril and Prinivil), Moexipril (Univasc), Perindopril (Aceon), Quinapril (Accupril), Ramipril (Altace), and Trandolapril (Mavik).*
I agree, I am not taking one of the above medications
I disagree, I am taking one of these medications

Please list any allergies to medications, ingredients or products. If none, type "NONE" *
Have you ever had an adverse/allergic reaction to Hyaluronic Acid filler?*
No
Yes

If yes, please list and describe allergic reaction.
Do you have any allergies to anesthetic? (topical or injectable)*
No
Yes
I am NOT pregnant or breastfeeding*
No, I am not pregnant or breastfeeding.
Yes, I am pregnant or breastfeeding.
I agree that there is a risk of bruising with any injectable treatment and that bruising may last up to two weeks.*
No, I disagree and I do not want to bruise. Unfortunately we cannot guarantee that you wont bruise.
Yes, I agree to the risk.
I'm interested in learning more about.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Coolsculpting (fat reduction and body contouring)
Cortisone injections for cystic acne
Developing a customized 3, 6 or 12 month skin care plan
Eyelash extensions
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Laser Hair Removal
Micro-blading eyebrows
Microdermabrasion
Microneedling
Platelet Rich Plasma (PRP) facial and/or Hair restoration
Red Light therapy/Infrared
Reducing melasma (pregnancy mask)
Reducing rosacea
Removing broken capillaries
Removing brown spots/sun damage
Skin tightening
Tattoo removal
Teeth whitening
Ultherapy or High Intensity Focused Ultrasound (HIFU)
Vitamin B-12 injections

Have you received hyaluronic acid fillers in the past? If so, please list the type, when your last treatment was, and what area(s) were treated. *
Eighth Patient's Name

First Name*

Middle Name

Last Name*
Eighth Patient's Date of Birth*
Eighth Patient's Information

Please list all medical conditions, past and present. Are you currently under the care of a doctor/specialist?

Are you currently on any medications? (prescription, herbal supplements, and/or vitamins?) If "yes" please list all medications, dosage and reason for taking

Do you have a history of any autoimmune disorders or a history of oral cold sores? Please list otherwise leave blank.
I agree I am NOT taking any of the following ACE Inhibitors (heart medication): Benazepril (Lotensin), Captopril (Capoten), Enalapril/Enalaprilat (Vasotec oral and injectable), Fosinopril (Monopril), Lisinopril (Zestril and Prinivil), Moexipril (Univasc), Perindopril (Aceon), Quinapril (Accupril), Ramipril (Altace), and Trandolapril (Mavik).*
I agree, I am not taking one of the above medications
I disagree, I am taking one of these medications

Please list any allergies to medications, ingredients or products. If none, type "NONE" *
Have you ever had an adverse/allergic reaction to Hyaluronic Acid filler?*
No
Yes

If yes, please list and describe allergic reaction.
Do you have any allergies to anesthetic? (topical or injectable)*
No
Yes
I am NOT pregnant or breastfeeding*
No, I am not pregnant or breastfeeding.
Yes, I am pregnant or breastfeeding.
I agree that there is a risk of bruising with any injectable treatment and that bruising may last up to two weeks.*
No, I disagree and I do not want to bruise. Unfortunately we cannot guarantee that you wont bruise.
Yes, I agree to the risk.
I'm interested in learning more about.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Coolsculpting (fat reduction and body contouring)
Cortisone injections for cystic acne
Developing a customized 3, 6 or 12 month skin care plan
Eyelash extensions
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Laser Hair Removal
Micro-blading eyebrows
Microdermabrasion
Microneedling
Platelet Rich Plasma (PRP) facial and/or Hair restoration
Red Light therapy/Infrared
Reducing melasma (pregnancy mask)
Reducing rosacea
Removing broken capillaries
Removing brown spots/sun damage
Skin tightening
Tattoo removal
Teeth whitening
Ultherapy or High Intensity Focused Ultrasound (HIFU)
Vitamin B-12 injections

Have you received hyaluronic acid fillers in the past? If so, please list the type, when your last treatment was, and what area(s) were treated. *
Ninth Patient's Name

First Name*

Middle Name

Last Name*
Ninth Patient's Date of Birth*
Ninth Patient's Information

Please list all medical conditions, past and present. Are you currently under the care of a doctor/specialist?

Are you currently on any medications? (prescription, herbal supplements, and/or vitamins?) If "yes" please list all medications, dosage and reason for taking

Do you have a history of any autoimmune disorders or a history of oral cold sores? Please list otherwise leave blank.
I agree I am NOT taking any of the following ACE Inhibitors (heart medication): Benazepril (Lotensin), Captopril (Capoten), Enalapril/Enalaprilat (Vasotec oral and injectable), Fosinopril (Monopril), Lisinopril (Zestril and Prinivil), Moexipril (Univasc), Perindopril (Aceon), Quinapril (Accupril), Ramipril (Altace), and Trandolapril (Mavik).*
I agree, I am not taking one of the above medications
I disagree, I am taking one of these medications

Please list any allergies to medications, ingredients or products. If none, type "NONE" *
Have you ever had an adverse/allergic reaction to Hyaluronic Acid filler?*
No
Yes

If yes, please list and describe allergic reaction.
Do you have any allergies to anesthetic? (topical or injectable)*
No
Yes
I am NOT pregnant or breastfeeding*
No, I am not pregnant or breastfeeding.
Yes, I am pregnant or breastfeeding.
I agree that there is a risk of bruising with any injectable treatment and that bruising may last up to two weeks.*
No, I disagree and I do not want to bruise. Unfortunately we cannot guarantee that you wont bruise.
Yes, I agree to the risk.
I'm interested in learning more about.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Coolsculpting (fat reduction and body contouring)
Cortisone injections for cystic acne
Developing a customized 3, 6 or 12 month skin care plan
Eyelash extensions
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Laser Hair Removal
Micro-blading eyebrows
Microdermabrasion
Microneedling
Platelet Rich Plasma (PRP) facial and/or Hair restoration
Red Light therapy/Infrared
Reducing melasma (pregnancy mask)
Reducing rosacea
Removing broken capillaries
Removing brown spots/sun damage
Skin tightening
Tattoo removal
Teeth whitening
Ultherapy or High Intensity Focused Ultrasound (HIFU)
Vitamin B-12 injections

Have you received hyaluronic acid fillers in the past? If so, please list the type, when your last treatment was, and what area(s) were treated. *
Tenth Patient's Name

First Name*

Middle Name

Last Name*
Tenth Patient's Date of Birth*
Tenth Patient's Information

Please list all medical conditions, past and present. Are you currently under the care of a doctor/specialist?

Are you currently on any medications? (prescription, herbal supplements, and/or vitamins?) If "yes" please list all medications, dosage and reason for taking

Do you have a history of any autoimmune disorders or a history of oral cold sores? Please list otherwise leave blank.
I agree I am NOT taking any of the following ACE Inhibitors (heart medication): Benazepril (Lotensin), Captopril (Capoten), Enalapril/Enalaprilat (Vasotec oral and injectable), Fosinopril (Monopril), Lisinopril (Zestril and Prinivil), Moexipril (Univasc), Perindopril (Aceon), Quinapril (Accupril), Ramipril (Altace), and Trandolapril (Mavik).*
I agree, I am not taking one of the above medications
I disagree, I am taking one of these medications

Please list any allergies to medications, ingredients or products. If none, type "NONE" *
Have you ever had an adverse/allergic reaction to Hyaluronic Acid filler?*
No
Yes

If yes, please list and describe allergic reaction.
Do you have any allergies to anesthetic? (topical or injectable)*
No
Yes
I am NOT pregnant or breastfeeding*
No, I am not pregnant or breastfeeding.
Yes, I am pregnant or breastfeeding.
I agree that there is a risk of bruising with any injectable treatment and that bruising may last up to two weeks.*
No, I disagree and I do not want to bruise. Unfortunately we cannot guarantee that you wont bruise.
Yes, I agree to the risk.
I'm interested in learning more about.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Coolsculpting (fat reduction and body contouring)
Cortisone injections for cystic acne
Developing a customized 3, 6 or 12 month skin care plan
Eyelash extensions
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Laser Hair Removal
Micro-blading eyebrows
Microdermabrasion
Microneedling
Platelet Rich Plasma (PRP) facial and/or Hair restoration
Red Light therapy/Infrared
Reducing melasma (pregnancy mask)
Reducing rosacea
Removing broken capillaries
Removing brown spots/sun damage
Skin tightening
Tattoo removal
Teeth whitening
Ultherapy or High Intensity Focused Ultrasound (HIFU)
Vitamin B-12 injections

Have you received hyaluronic acid fillers in the past? If so, please list the type, when your last treatment was, and what area(s) were treated. *
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Please list all medical conditions, past and present. Are you currently under the care of a doctor/specialist?

Are you currently on any medications? (prescription, herbal supplements, and/or vitamins?) If "yes" please list all medications, dosage and reason for taking

Do you have a history of any autoimmune disorders or a history of oral cold sores? Please list otherwise leave blank.
I agree I am NOT taking any of the following ACE Inhibitors (heart medication): Benazepril (Lotensin), Captopril (Capoten), Enalapril/Enalaprilat (Vasotec oral and injectable), Fosinopril (Monopril), Lisinopril (Zestril and Prinivil), Moexipril (Univasc), Perindopril (Aceon), Quinapril (Accupril), Ramipril (Altace), and Trandolapril (Mavik).*
I agree, I am not taking one of the above medications
I disagree, I am taking one of these medications

Please list any allergies to medications, ingredients or products. If none, type "NONE" *
Have you ever had an adverse/allergic reaction to Hyaluronic Acid filler?*
No
Yes

If yes, please list and describe allergic reaction.
Do you have any allergies to anesthetic? (topical or injectable)*
No
Yes
I am NOT pregnant or breastfeeding*
No, I am not pregnant or breastfeeding.
Yes, I am pregnant or breastfeeding.
I agree that there is a risk of bruising with any injectable treatment and that bruising may last up to two weeks.*
No, I disagree and I do not want to bruise. Unfortunately we cannot guarantee that you wont bruise.
Yes, I agree to the risk.
I'm interested in learning more about.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Coolsculpting (fat reduction and body contouring)
Cortisone injections for cystic acne
Developing a customized 3, 6 or 12 month skin care plan
Eyelash extensions
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Laser Hair Removal
Micro-blading eyebrows
Microdermabrasion
Microneedling
Platelet Rich Plasma (PRP) facial and/or Hair restoration
Red Light therapy/Infrared
Reducing melasma (pregnancy mask)
Reducing rosacea
Removing broken capillaries
Removing brown spots/sun damage
Skin tightening
Tattoo removal
Teeth whitening
Ultherapy or High Intensity Focused Ultrasound (HIFU)
Vitamin B-12 injections

Have you received hyaluronic acid fillers in the past? If so, please list the type, when your last treatment was, and what area(s) were treated. *
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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