Surveypoint

Q1

Appointment Date*

Date

Q2

Appointment Time*

Hour

1

2

3

4

5

6

7

8

9

10

11

12

Q3

Appointment Time*

Minutes

00

10

20

30

40

50

Q4

Appointment Time*

AM/PM Option

AM

PM

Q5

Name

First Name

Q6

Name

Last Name

Q7

Email

Q8

Address*

Street Address

Q9

Address*

Street Address Line 2

Q10

Address*

City

Q11

Address*

State / Province

Q12

Address*

Postal / Zip Code

Q13

Phone Number*

Area Code

Q14

Phone Number*

Phone Number

Q15

If yes, when was your last procedure?

Q16

If yes, please specify:

Q17

Is there any additional information about you that we should know before starting your treatment?

Q18

Signature*

Q19

Consent for Hyaluronic Lip Filler Procedure*

I am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant or nursing and desire to receive the hyaluronic lip filler treatment.

If an unforeseen condition arises in the course of the procedure , I authorize my practinioner to use her proffesional judgement to decide what she feels is necessary under the given circumstances. I accept the responsibility for determining the shape and position of the hyaluronic lip filler procedure as agreed during consultation. I fully understand and accept that hyaluronic acid products are used during the procedure and that the result achieved may disappear over a period of 2-4 months

I have been informed that the highest standards of hygiene are met and that sterile, disposable supplies are used for each individual client, procedure, and visit.

I understand and accept that each procedure is a process sometimes requiring multiple applications of filler to achieve desired results and that 100% success cannot be guaranteed during the first procedure. I understand that I may have to return for a repeat procedure.

The result of the procedure can be affected by the following: medication, skin characteristics, personal pH balance of your skin, alcohol intake, smoking post procedure after care.

Upon completion of the procedure there might be swelling and redness of the skin, which will subside within 1-4 days. In some cases, bruising may occur. You may resume normal activities following the procedure, however, using cosmetics, excessive perspiration and heavy alcohol consumption, should be limited until the skin has fully healed. Please see after care instructions for more details. The procedure results will look acceptable for you to appear in public.

I have been advised that the true shape and fullness will be seen in 2-4 weeks after each procedure, and that the results may vary according to metabolism, lifestyle, age, and skin condition. I understand that some skin types accept filler more readily and no guarantee on exact results can be given.

To my knowledge, I do not have any physical, mental or medical impairment or disability that might affect my well being as a direct or indirect result of my decision to have the procedure done at this time.

I agree to follow all pre-procedure and post procedure instructions as provided and explained to me by the technician. Failure to do so may jeopardize my chances for a successful procedure.

I can confirm that I have received a copy of after care details.

I have been informed at the nature, risks, an possible complications and consequences of temporary fillers. I understand that the hyaluronic lip filler procedure carries unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, scarring, inconsistent results, and spreading, fanning or fading filler. I understand the filler may pool resulting in temporary bumps under the skin.

I fully understand this is a cosmetic procedure and therefore not an exact science but an art. I request the hyaluronic lip filler procedure and accept the temporary nature of this procedure as well as the possible complications and consequences of the said procedure.

I understand that if I have any skin treatments, injectables, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my hyaluronic lip filler procedure. I acknowledge some of these potential adverse changes may not be correctable.

I certify that I have read and checked the above paragraphs and have explained to my understanding the consent and procedure permit. I accept full responsibility for the decision to have this cosmetic hyaluronic lip filler procedure done.

I give the practitioner and any of her students the permission to perform my hyaluron lip filler procedure.

I consent to my temperature being taken.

Q20

I understand the following completely (please check each statement):*

Hyaluronic lip filler results can last 2-4 months depending on how my skin reacts to the procedure. There may be unevenness and/or bumps under the skin. The result may not be what I expected to receive. I understand this is a temporary procedure that may take numerous follow ups and touch ups to get a desired result.

There is no warranty or guarantee made to me as a result of this procedure and the final result cannot be guaranteed. There are no refunds for this procedure, as results will vary and individual results are not guaranteed

I have seen and agree with the shape that my technician and her students discussed. I understand that this is a guideline for the shape and size of my lip design and it may vary slightly once the procedure is done.

There may be risks and hazard related to performing this procedure.

There may be discomfort and pain during this procedure.

There is a possibility of bleeding, swelling, redness, and allergic reactions to numbing.

Hyaluronic lip filler is considered temporary and can/will fade over time.

Dissolving procedures may be required to remove filler from the skin.

Final results cannot be determined until areas are completely healed at 2-4 weeks.

I understand that the hyaluronic lip filler procedure cannot be guaranteed and results cannot be predicted, as there are many variables that contribute to the final results, such as aftercare, skin type, lifestyle, etc.

I have received post care instructions and will follow the, to ensure results of my procedure are satisfactory.

I am NOT pregnant.

I am NOT under the influence of drugs and/or alcohol or any other mind altering substance.

I fully understand the procedure and give permission to my technician to perform the service of hyaluronic lip filler and all procedure and steps involved.

I have truthfully filled out the consent form and have informed my technician of all medications I have taken.

I release my practitioner and her students of all claims and injury, seen or unseen that may occur as a result of this procedure.

Needle Less Lip Filler -Form Fill

Appointment Date*

Appointment Time*

Appointment Time*

Appointment Time*

Name

Name

Email

Address*

Address*

Address*

Address*

Address*

Phone Number*

Phone Number*

If yes, when was your last procedure?

If yes, please specify:

Is there any additional information about you that we should know before starting your treatment?

Signature*

Consent for Hyaluronic Lip Filler Procedure*

I understand the following completely (please check each statement):*