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Are you currently under a physician’s care for any medical condition?Â
Are you taking any medications (prescription or over-the-counter)?
Do you have any allergies (medications, foods, etc.)?
Have you had any previous reactions to injections?
Are you pregnant, trying to become pregnant, or breastfeeding?
Acknowledgement and Consent
I acknowledge that I have been informed about the nature of the injection procedure, including the potential risks and benefits.
I understand that no procedure is without risks, and possible side effects may include but are not limited to infection, swelling, bruising, and allergic reactions.
I have had the opportunity to ask questions and discuss any concerns with the practitioner.
I understand that multiple treatments may be necessary to achieve the desired results and that results may vary.
I agree to follow all post-procedure care instructions provided by the practitioner.
I consent to the administration of the injectable procedure by the named practitioner.
Practitioner Declaration
I have discussed the procedure and the associated risks with the client. I believe the client understands and consents to the procedure.