Using the digital waiver for beauty salon system is a good choice for medical companies.

Name: *

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Known Allergies: Please enter your answer here.

Current Medications: Please enter your answer here.

Have you ever fainted before or after an injection? *

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Are you taking blood thinners (including aspirin)? *

Yes

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Do you suffer from cold sores? *

Yes

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(Women only) are you pregnant or breast feeding?

Yes

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Botulinum toxin type A is a neurotoxin protein produced by the bacterium clostridium botulinum and related species. A cosmetic solution of this toxin is injected with a very small needle into the facial muscle; you should see the benefits develop over the next two to seven days. A decreased appearance of facial lines and decreased local muscle activity will be the expected result of the treatment. Possible side effects include headache, respiratory infection, flu syndrome, temporary eyelid droop, and nausea (these are rarely experienced). Results are temporary and several sessions may be needed to achieve optimum results and maintain the effect. Effects typically last for 3-4 months but can vary for each individual.

Hyaluronic Acid is a natural substance found in the human body used to deliver nutrients and hydrate the skin by bonding with water. Dermal fillers are manufactured by cross linking hydronic acid into a gel form. It is injected to provide volume to facial structures and tissues. It can be used to correct facial lines, wrinkles and folds, for lip enhancement and for shaping facial contours. Effects typically last for 6-12 months depending on which product is used and can vary for each individual.

Risks associated with any invasive procedure, and in this specific instance include but are not limited to:

1) Post treatment discomfort, swelling, redness, bruising and discolouration

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) Localised necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occurs.

I hereby give consent for the Nurse, Meriah Stack, to perform a treatment plan approved and prescribed by the supervising Doctor, Joni Feldman.

I consent to photographs to be taken for medical records and marketing purposes.

I have been provided with information on the treatment and aftercare required.

I hereby certify that I have been fully informed of the nature and purpose of the procedure, expected outcome and possible complications. I understand that there can be no guarantee or assurance as to the final result that may be obtained. All of my questions have been answered to my satisfaction. The risks and benefits of this treatment have been explained to me and I understand that I have the right to refuse treatment.

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Date: *

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Witness Name:

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Date:

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