1. Patient Medical History Form

Full Name: *

Date of Birth: *

Phone Number: *

Email Address: *

Medical History (check all that apply):

Medical history

Pregnant or breastfeeding

Allergies (especially lidocaine or fillers)

Autoimmune disorders

Blood clotting disorders

Neurological condition

Current medications (esp. blood thinners, aspirin, steroids)

Prior cosmetic treatments (fillers, Botox, surgery):

Additional information (if any of the above applies to you)

Emergency Contact:

Informed Consent for Lip Filler Treatment

I acknowledge that: *

Dermal fillers are temporary and results vary per patient

Risks include swelling, bruising, asymmetry, infection, lumps, vascular occlusion, necrosis, or allergic reaction

I understand that results are not guaranteed.

I consent to photographs being taken for medical documentation.

I have disclosed all medical history and medications.

I voluntarily consent to treatment and assume all risks.

Patient Name: *

Patient Signature: *

Clear

Date: *

3. Aftercare Instructions (Acknowledgment Form)

I agree to terms & conditions provided by the company.

I understand I should:

Avoid alcohol, blood thinners, and strenuous exercise for 24–48 hrs

Use ice packs to reduce swelling and bruising.

Avoid touching/massaging unless instructed.

- Expect swelling and bruising for up to 2 weeks

Seek immediate medical help if experiencing severe pain, blanching skin, vision changes, or difficulty breathing.

Patient Signature:

Clear

Date

Deposit & Risk Acknowledgment Policy

Non-Refundable Deposit

I understand and agree that any deposit made for medical consultations, procedures, or treatments is non-refundable under all circumstances. This applies regardless of cancellation, rescheduling, or change of decision on my part.

Assumption of Risk

I acknowledge that all medical treatments, procedures, or interventions carry inherent risks. I have been informed of the potential benefits, risks, and alternatives related to my care, and I have had the opportunity to ask questions. I voluntarily assume full responsibility for any and all risks, outcomes, or complications that may arise from the medical care I receive. I release the provider and facility from liability for outcomes that are not guaranteed and may vary from patient to patient

Confirmation of Understanding

By signing below, I confirm that:

- I have read and fully understood this policy

- I understand the deposit is non-refundable.

- I accept and assume all risks related to my treatment.

- I sign this document voluntarily and without coercion.

Patient Name

Patient Signature:

Clear

Date

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