Needle Less Injections Consent Form

Medical History
NEEDLE-LESS LIPO INJECTIONS
General Medical Aesthetics Release Form / Hold Harmless
I hereby consent to and authorize IRIDIAN TORRES to perform the following treatment:

Needle Less INJECTIONS

Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications of this treatment. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.

I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult IRIDIAN TORRES immediately.

I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies, prescription drugs or products I am currently ingesting or using topically.

I have read and fully understand this agreement and all information detailed above. I understand the treatment and accept the risks. All my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the technician (nor the establishment), whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today. I also release IRIDIAN TORRES (BODY BAR ESTHETICS ) of any liability that may arise from this procedure.
Signature*
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Full Name*
First NameLast Name
Phone Number*
DOB blanks* ADDRESS blank*
Check the conditions that apply to you or to any members of your immediate relatives:
CancerCardiac diseaseDiabetesPsychiatric disorderHysterectomyAIDS/HIVPSORIASISSpinal InjuryKeloid ScarringMenopauseHigh/Low Blood PressureClaustrophobiaHormone ImbalanceHapatitis A/B/CRosaceaCold SoreBlood Clot DisorderEczemaImmune DisorderSkin Disease DisorderVariocoseVeins/PhlebitisPacemaker/DefibrillatorThyroid DisorderBlush/ Redden EasilyDeppression/AnxietyBruise EasilyLupsFibromyalgiaCirculation DisorderMetal Implants
Are you currently taking any medication?*
YesNo
Did you follow all pre-care instructions?*
YesNo
Are you currently breastfeeding?*
YesNo
Do You Follow a Restricted Diet?*
YesNo
Allergic to SeaFood?*
YesNo
Are you currently under the care of a physician ordermatologist*
YesNo
Do you have any medication allergies?*
YesNoNot Sure
Any Surgery's in the last six months?*
YesNoNot Sure
Any dermal injections/fillers with in the last 6months?*
YesNoNot Sure
Are you using any products that contain Retin –A,Renova, Adapalene Hydroxyl Acid, Differin, Glycolic Acid, AHA/BHA, SalicylicAcid, Lactic Acid, Retinol/Vitamin A, Accutane or any other prescription orover the counter skin product?*
YesNoNot Sure
Have you ever had any allergic reaction to any skinproducts? ?*
YesNoNot Sure
What is your Gender?*
MaleFemale
In Case of Emergency Contact Number*
Please enter a valid phone number.
Client Consent: I understand, have read and completed the questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform IRIDIAN TORRES of my current medical or health conditions and to update this history. I understand that the services offered are not a substitute for medical care and any information provided by IRIDIAN TORRS is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid IRIDIAN TORRES in giving better service and is completely confidential. The treatments I receive here are voluntary and I release IRIDIAN TORRES and BODY BAR ESTHETICS from any liability and assume full responsibility thereof.
Signature*
Clear
Photographic Consent:
I consent to photographs being taken before, during and after each procedure. I agree to
these photos being stored electronically in my case file and will be used only with my written
consent for promotional purposes.
Patch Test Waiver:
(A) I understand that a skin test can determine whether or not I will experience a reaction to
the products used within 48 hours prior to the treatment. However, I accept this will be
inconclusive as to whether I have an allergic reaction at any time in the future.
I therefore waive my option to an allergy test and wish to proceed with treatment
(B) I have undergone or been offered an allergy test prior to my initial treatment. I therefore
release (IRIDIAN TORRES BODY BAR ESTHETICS) from liability related to any
allergic reaction I may experience associated with either the application of the
injection serum or any other products used before, during and after my procedure,
immediately or at a later date.
Signature*
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Should be Empty:

Medical History