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Name*Email Address*Address*Cell Phone Number*Please indicate the services you are interested in:Laser Hair RemovalSkin RejuvenationWeight ManagementLeg VeinsAcne/ScarringSkin Care ProductsOtherDo you currently have, or have you ever had any of the following conditions:Seizure and/or EpilepsyDiabetesNumbness in the areaLupusSkin DisordersVitiligoKeloid/Hypertrophic ScarringBlood Clots/ Bleeding DisordersVaricose VeinsPregnancy/ Trying to get pregnantCancer and/ or Precancerous LesionsPacemakers/Internal Pacing DevicesInternal Metal Devices (rods,screws,plates)Medical Clearance Letter Required if yes to any of the following:HIV/AIDSMultiple SclerosisChemotherapy/RadiationMedication History, Check any boxes that apply:Retinol or Retin-AAcne MedicationsOral ContraceptivesAccutaneAntibioticsDo you have any of the following?Permanent Make-UpTattoosRecent Cosmetic ProceduresBotox/FillersSelf Tanner on areas being treatedSigning the box below indicates I have answered all the questions truthfully and to the best of my knowledge. *Botox*I understand that I will be injected with Botulinum A Toxin (Botox) in the area of the glabella muscles to paralyze these muscles temporarily or in the forehead or crows feet around the lateral area of the eyes.Botulinum A Toxin (Botox) injection has been FDA approved for use in the cosmetic treatment for glabellar frown lines only - the wrinkles between the eyebrows.Injection of Botox into the small muscles between the brows causes those specific muscles to halt their function (be paralyzed), thereby improving the appearance of the wrinkles. I understand the goal is to decrease the wrinkles in the treated area. This paralysis is temporary, and re-injection is necessary within three to four months. It has been explained to me that other temporary and more permanent treatments are available.The possible side effects of Botox include but are not limited to:1. Risks: I understand there is a risk of swelling, rash, headache, local numbness, pain at the injection site, bruising, respiratory problems, and allergic reaction.2. Infection: Infections can occur which in most cases are easily treatable but in rare cases a permanent scarring in the area can occur.3. Most people have lightly swollen pinkish bumps where the injections went in, for a couple of hours or even several days.4. Although many people with chronic headaches or migraines often get relief from Botox, a small percent of patients get headaches following treatment with Botox, for the first day. In a very small percentage of patients these headaches can persist for several days or weeks.5. Local numbness, rash, pain at the injection site, flu like symptoms with mild fever, back pain.6. Respiratory problems such as bronchitis or sinusitis, nausea, dizziness, and tightness or irritation of the skin.7. Bruising is possible anytime you inject a needle into the skin. This bruising can last for several hours, days, weeks, months and in rare cases the effect of bruising could be permanent.8. While local weakness of the injected muscles is representative of the expected pharmacological action of Botox, weakness of adjacent muscles may occur as a result of the spread of the toxin.9. Treatments: I understand more than one injection may be needed to achieve a satisfactory result.10. Another risk when injecting Botox around the eyes included corneal exposure because people may not be able to blink the eyelids as often as they should to protect the eye. This inability to protect the eye has been associated with damage to the eye as impaired vision, or double vision, which is usually temporary. This reduced blinking has been associated with corneal ulcerations. There are medications that can help lift the eyelid, however, if the drooping is too great the eye drops are not that effective. These side effects can last for several weeks or longer. This occurs in 2-5 percent of patients.11. I will follow all aftercare instructions as it is crucial I do so for healing.As Botox is not an exact science, there might be an uneven appearance of the face with some muscles more affected by the Botox than others. In most cases this uneven appearance can be corrected by injecting Botox in the same or nearby muscles. However in some cases this uneven appearance can persist for several weeks or months.This list is not meant to be inclusive of all possible risks associated with Botox as there are both known and unknown side effects associated with any medication or procedure.Botox should not be administered to a pregnant or nursing woman.Additionally,The number of units injected is an estimate of the amount of Botox required to paralyze the muscles. I understand there is no guarantee of results of any treatment. I understand the regular charge applies to all subsequent treatments. No refunds will be given for treatments received.I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I further agree in the event of non-payment, to bear the cost of collection, and/or Court cost and reasonable legal fees, should this be required.I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs, and that I have had sufficient opportunity for discussion and to ask questions. I consent to the BOTOX Cosmetic treatment today and for all subsequent treatments.Filler*Treatment with Restylane, Juvederm, Perlane, or Collagen can smooth out folds and wrinkles, add volume to the lips, and contour facial features that have lost their fullness due to aging, sun exposure, illness, etc. Facial rejuvenation can be carried out with minimal complications. These dermal fillers are injected into the skin with a very fine needle. The products produce a natural volume under the wrinkle, which is lifted up and smoothed out. The results can often be seen immediately. Treating wrinkles with these dermal fillers is fast and safe and leaves no scars or other traces on the face.RISKS AND COMPLICATIONSIt 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, discoloration2) Post treatment infection associated with any transcutaneous injection3) Allergic reaction4) Reactivation of Herpes (cold sores)5) Lumpiness, visible yellow or white patches in approximately 20% of cases6) Granuloma formation7) Localized Necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occurs.PHOTOGRAPHSI authorize the taking of clinical photographs and their use for scientific purposes both in publications and presentations. I understand my identity will be protected.PREGNANCY, ALLERGIES & DISEASEI 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 any of the above mentioned dermal fillers. I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to Lidocaine.If receiving Collagen I have read the brochure titled "Zyderm®/Zyplast® or Cosmoplast™/Cosmoderm™Collagen Explained" in its entirety and have discussed the risks and benefits of injectable collagen treatment with my physician and/or his/her representative and have had all my questions answered. I understand the information provided.PAYMENTI understand that this procedure is cosmetic and that payment is my responsibility.RESULTSI am aware that full correction is important and that follow-up touch ups/treatments will be needed to maintain the full effects. I am aware that the duration of treatment is dependent on many factors including but not limited to: age, sex, tissue condition, my general health and life style conditions, and sun exposure. The correction, depending on these factors may last 3-6 months and in some cases longer. I been instructed in and understand post treatment instructions and have been given a copy of them.I hereby voluntarily consent to treatment. The procedure (s) has been explained to me. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure. I certify that if I have any changes occur in my medical history I will notify the office.Photo Facial *I consent to and authorize my practitioner to perform treatments on me. Light can be used effectively to destroy targets located in the skin with minimum damage to the surrounding tissues. Light is used to lighten, fade or remove photo-damaged skin in a nonablative manner, a procedure known as photo rejuvenation. Visible sings of photo damage include wrinkling, enlarged pores, course skin texture, and pigment alterations.Photo-therapy, despite its high levels of efficacy and safety, is not free of side effects. Erythema (redness) and edema (swelling) of the treated area can occur but usually subsides within a few hours but can last up to seven days or longer. Irritation, itching, and/or a mild burning sensation or pain similar to sunburn may occur within 48 hours of treatment.Pigmentary changes such as hyper pigmentation and hypo pigmentation of the skin in the treated areas can occasionally occur. Mostly it is transient, lasting up to six months, but in rare cases it can be permanent. Most cases of hypo- or hyper-pigmentation occur in people with darker skin or when the treated area has been exposed to sunlight before or after treatment. Occasionally these pigmentary changes occur despite appropriate protection from the sun.Scarring, which can be hypertrophic or even keloid, can occur. Other known complications of this procedure include blisters, reddening, pinpoint pitted scars, bruising, superficial crusting, burns, pain, and infections. These side effects are usually temporary, lasting from five to ten days but can be permanent as well.The skin at or near the treatment site may become fragile. If this happens, makeup should be avoided and the area should not be rubbed, as this might tear the skin. A blue-purple bruise may appear on the treated area, which might last from five to fifteen days. As the bruise fades, there may be rust-brown discoloration of this skin, which fades in one to three months or longer.Additionally, there is a known and expected loss of hair in the treated areas. In a very small percent of people there is new hair growth in the surrounding areas being treated.Even though appropriate measures are taken to reduce side effects, they cannot be completely eliminated in every case. I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume these risks. There may be other treatment options, such as injections, other types of lasers/light sources or peels. With this in mind, I am choosing this non-invasive treatment for vascular and/or pigment lesions and other indicated skin conditions.Eye damage can occur from the light and therefore protective eyewear must be worn during all phototherapy sessions.I have read and understand the Pre and Post-Treatment Instructions. I agree to follow these instructions carefully. I understand that compliance with recommended pre and post procedure guidelines are crucial for healing, prevention of scarring, and other side effects and complications such as hyper pigmentation, hypo pigmentation, and other skin textural changes.I understand that this examination is not meant to replace the necessity for a complete dermatological examination.Photographs: I give permission for my photographs to be used to help document my treatment course. Complete confidentiality will be maintained.No guarantee, warranty, or assurance as been made to me as to the results that may be obtained. I am aware that follow-up treatments may be necessary for desired results. Most patients require a number of treatments over several months with gradual results occurring over this time. Clinical results will vary per patient. I agree to adhere to all safety precautions and regulations during the treatment. No refunds will be given for treatments received.I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment.The nature and purpose of the treatment have been explained to me. I have read and understand this agreement. 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 my practitioner and medical staff, and specific technicians from liability associated with this 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. Skin Tightening *This consent is designed to give me the information needed to make an informed decision to undergo Skin Tightening.Treatment with Candela Gentle Yag.I clearly understand and accept the following:The treatment involves wavelength, exposure, duration and energy levels carefully chosen to selectively firm and tighten the skin in the treatment area. Skin Tightening Treatment involves a series of at least 6 treatments done once a month for 6 months. The procedure’s effectiveness has been documented in studies. However, it is important to note that the duration of the results can vary and a maintenance program may be needed. Individual results may vary and a reduction in wrinkles to your satisfaction cannot be guaranteed.Risks and Complications:Discomfort: My provider does not guarantee pain-free treatments. Individual responses to Skin Tightening Treatment may vary and the amount of pain varies from person to person.Possible Side Effects: Scarring, discoloration or lightening of skin in the treatment area. To avoid the chance of scarring, it is important that you follow all pre and post-treatment instructions carefully. Short-term side effects following Skin Tightening Treatment include: pinkness, mild tingling, warm sensation, bruising, blistering or swelling.Instructions: If you experience any of these side effects, you must contact us as soon as possible so the area can be evaluated and we can advise you on how to care for the area, and so that we can document the occurrence.Sun Exposure/Sun Tanning/Artificial Tanning: I agree that I will not engage in direct sun tanning, tanning bed or booth tanning, or artificial product tanning while undergoing Skin Tightening Treatments. I further agree that if I will be exposed to the sun, I must protect my skin with a complete sun block every 2 hours and must also protect myself with a hat or light clothing, as needed.Health Conditions and Contraindications: Pregnancy, acutance within the last 3 months, pacemaker, internal defibrillator, any internal metal device (surgical screws, pins, plates, or implants, etc.) in the area to be treated. A letter of clearance is needed for clients with chemo or radiation therapy who are HIV positive, and with multiple sclerosis (with confirmation that the area to be treated is not numb). Treatment is inadvisable on areas of the body that have decreased numbness. Skin Tightening Treatment is advisable for people under the age of 12 years. Use of photosensitizing medications may cause increased skin sensitivity to Skin Tightening Treatment.Cold Sores: I understand that if I have a history of cold sores in or near the treatment area, it is advised that I require a prescription for pre and post treatment anti-viral medication, which should be started the day of or 1 day prior to Skin Tightening Treatment and continued for the full course.Eye Exposure: While there is minimal risk of inadvertent eye exposure to laser, safeguards will be provided including the use of protective eyewear during treatment. You must wear protective eyewear/goggles at all times during the treatment to protect your eyes from the intense light.Instructions: For the Skin Tightening Treatment to be optimally successful, I accept responsibility in complying with the pre and post-treatment’s care instructions and products advised by my provider.VI Peel *I authorize the chemical peel listed above, to my face and / or neck, chest and hands.Depending on the chemical peel site, there may be redness and/or irritation and discoloration (dark tan and pink marks) that can persist for several days or weeks.Occasionally hyper pigmentation or hypo pigmentation might develop after the peel that might persist for weeks or months.With each chemical peel results are achieved. Nevertheless, no guarantees can be made as to the final results. Any number of chemical peels may be required to achieve desired results, depending on the present skin condition, skin care maintenance program, age and lifestyle of the patient.Once the desired results are achieved, I understand that maintenance peels are necessary to sustain the rejuvenative results. The frequency depends on the individual’s own genetics, age and lifestyle.Once peeling process is complete it is essential to follow instructions and/or use the V.I. Derm skin care line, or other, to maintain results and avoid any future complications especially hyper pigmentation.I understand that this peel is made of the strongest acids such as Phenol and Trichloroacetic acid, also referred to as TCA, salicylic acid, among others. The exact composition is proprietary information of the V.I. Peel system, and I waive any rights, present or future, I may have as to request to divulge the exact composition or concentrations.Services are cosmetic in nature, and are non refundable. I understand that payment is my sole responsibility.I agree that this constitutes full disclosure, and that it supercedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have had sufficient opportunity for discussion and to ask questions.SkinPen *A consent form is a legal document between a patient and the medical professional who is providing a service or procedure. This verbiage is a suggestion only and should be approved and used to create your own consent form.DESCRIPTION OF THE PROCEDUREMicroneedling procedures allow for controlled induction of the skin’s self-repair mechanism by creating micro-“injuries” in the skin, which triggers new collagen synthesis. The result is smoother, younger-looking skin.Microneedling procedures are performed in a safe and precise manner with the use of the sterile needle head. The procedure is normally completed within 30–60 minutes, depending on the required procedure and anatomical site.SIDE EFFECTSAfter the procedure, the skin will be red and flushed in appearance, similar to a moderate sunburn. You may also experience skin tightness and mild sensitivity to touch on certain areas. This will diminish significantly within a few hours following the procedure. Within the next 24 hours, the skin will have returned to normal. After three days, there is rarely any evidence that the procedure has taken place.CONTRAINDICATIONSMicroneedling is contraindicated for patients with: keloid scars, scleroderma, collagen vascular diseases or cardiac abnormalities, a hemorrhagic disorder or haemostatic dysfunction, active bacterial or fungal infection.PRECAUTIONS AND WARNINGSMicroneedling has not been evaluated in the following patient populations, and as such, precautions should be taken when determining whether the SkinPen procedure is adequate for the patient: scars and stretch marks less than one year old; women who are pregnant or nursing; keloid scars; patients with history of eczema, psoriasis and other chronic conditions; patients with history of actinic (solar) keratosis; patients with history of herpes simplex infections; diabetics or patients with wound-healing deficiencies; patients on immunosuppressive therapy; and skin with presence of raised moles or warts on targeted area.PATIENT CONSENTI understand that results will vary among individuals. I understand that although I may see a change after my first procedure, I may require a series of sessions to obtain my desired outcome.The procedure and side effects have been explained to me including alternative methods, as have the advantages and disadvantages.I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated, therefore, there can be no guarantee as expressed or implied either as to the success or other result of the procedure. I am aware that microneedling procedure is not permanent and natural degradation may occur over time.I state that I have read (or it has been read to me) and I understand this consent and I understand the information contained in it.I have had the opportunity to ask any questions about the procedure including risks or alternatives and acknowledge that all my questions about the procedure have been answered in a satisfactory manner.This consent form is valid until all or part is revoked by me in writing.Facial or Leg Veins *I hereby authorize my practitioner to remove or lighten the appearance of vascular lesions. The procedure involves using a laser or pulsed light device to coagulate the vessels or vascular lesion. It may take multiple treatments to obtain optimal results, and it is possible that the results will be minimal or not help at all. Light based devices will not prevent you from developing new veins. Although these devices are effective in most cases, no guarantees can be made.I am aware of the following possible experiences/risks:DISCOMFORT - Some discomfort may be excperienced during treatment.REDNESS/SWELLING/BRUSING - Short term redness or swelling of the treated area is common and may occur. There also may be experienced during treatment.PIGMENT CHANGES (Skin Color) - During the healing process, there is a possibility that the treated area can become either lighter (hypopigmentation) or darker (hyperpigmentation) in color compared to the surrounding skin. This is usually temporary, but, on a rare occasion, it may be permanent.WOUNDS - Treatment can result in burning, blistering, or bleeding of the treated areas. If any of these occur, please call our office.INFECTION - Infection is a possibility whenever the skin surface is disrupted, though proper wound care should prevent this. If signs of infection develop, such as pain, heat or surrounding redness, please call our office.SCARRING - Scarring is a rare occurrence, but it is a possibility if the skin surface is disrupted. To minimize the chances of scarring, it is IMPORTANT that you follow all post-treatment instructions provided by your healthcare staff.EYE EXPOSURE - Protective eyewear (shields) will be provided to you during the treatment. Failure to wear eye shields during the entire treatment may cause severe and permanent eye damage.I acknowledge the following points have been discussed with me:Potential benefits of the proposed procedure.Possible alternative procedures, such as sclerotherapy or surgery.Probability of success.Reasonably anticipated consequences if the procedure is not performedPossible complications/risks involved with the proposed procedure and subsequent healing periodPost-treatment instructionsFor women of childbearing age: By signing below I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of treatment. Furthermore, I agree to keep my practitioner and staff informed should I become pregnant during the course of treatment.Photographic documentation will be taken. I hereby authorize the use of my photographs for teaching purposes.Laser Hair Removal:*I hereby authorize my practitioner or any delegated associates, to perform laser hair removal on me.I understand that this procedure works on the growing hairs and not on dormant hairs.For this reason, complete destruction of all hair follicles from any one treatment is unlikely,and I understand that I will require several treatments to obtain a significant, long-term reduction of hair growth.I also understand some people may not experience complete hair loss even with multiple treatments and that it is only effective on hair with color and does not treat white, grey, blonde or red hair.I understand that genetics, hormones and hair color may interfere with hair loss and I may not respond at all.All of our unlimited laser hair removal packages purchased do not cover blond, grey, red, white or vellus hairs.All unlimited or guarantee purchases on any services are void if Angelic Skin Clinic closes for any reason. No refunds will be given.I am aware of the following possible experiences/risks:DISCOMFORT – Some discomfort may be experienced during treatment. REDNESS/SWELLING/BRUISING – Short term redness or swelling of the treated area is common and may occur. There also may be some bruising. PIGMENT CHANGES (Skin Color) – During the healing process, there is a possibility that the treated area can become either lighter (hypopigmentation) or darker (hyperpigmentation) in color compared to the surrounding skin. This is usually temporary, but, on a rare occasion, it may be permanent. WOUNDS – Treatment can result in burning or blistering of the treated areas.If any of these occur, please call our office. INFECTION – Infection is a possibility whenever the skin surface is disrupted, although proper wound care should prevent this.If signs of infection develop, such as pain, heat, or surrounding redness, please call our office. SCARRING – Scarring is a rare occurrence, but it is a possibility if the skin surface is disrupted. To minimize the chances of scarring, it is IMPORTANT that you follow all post treatment instructions carefully. EYE EXPOSURE – Protective eyewear or shields will be provided. It is important to keep these shields on at all times during the treatment in order to protect your eyes from injury. TATTOOS - Any tattoos on the treatment areas MUST be covered by the client before treatment begins.The technician takes no fault in any potential damage that could occur during treatment. The following points have been discussed with me:Potential benefits of the proposed procedure Possible alternative procedures such as electrolysis, waxing, tweezing and depilatories. Probability of success Reasonably anticipated consequences if the procedure is not performed Most likely possible complications/risks involved with the proposed procedure and subsequent healing period Post-treatment instructions For women of childbearing age: By signing below I indicate that I am not pregnant.Futhermore, I agree to keep my practitioner informed should I become pregnant during the course of treatment.Photographic documentation may be taken.I hereby authorize the use of my photographs for teaching purposes.I understand the potential risks, had the opportunity to ask questions, and consent to treatment with the laser. I am aware that all sales are final, and will not receive a refund for any services purchased.If for any reason I am unable to complete my packages purchased,I understand no refund will be issued for any treatments not used.By signing this form, I am stating I have read the above consent forms and agree to treatments for Laser Hair Removal, Botox, Filler, VI Peel, Photo Facial, Skin Tightening, SkinPen and/or Facial or Leg Vein Treatments. I understand the potential risks, had the opportunity to ask questions, and consent to treatments. I am aware that all sales are final, and will not receive a refund for any services purchased. If for any reason, I am unable to complete my packages purchased, I understand no refund will be issued for any treatments not used. I am also aware that if I no show or cancel an appointment within 24 hours, I will be charged a $35 fee before I am able to book any future appointments. I agree to receive email and/or text messages regarding Angelic Skin Clinic and Rodan + Fields. This site uses Google reCAPTCHA technology to fight spam. Your use of reCAPTCHA is subject to Google's Privacy Policy and Terms of Service.Send MessageThank you for completing your medical forms. Please refer to our Pre & Post Care Instructions for your service. We look forward to seeing you! / PreviousNextPausePlayClose
