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Consent Forms

New Patient Medical History

PERSONAL MEDICAL HISTORY:
SKIN HISTORY
Have you had:
Acne:
THE FITZPATRICK SKIN-TYPE CHART:

Genetic Disposition
Reaction to Sun Exposure
Tanning Habits
Have you had:
Do you have:

HIPPA Privacy Signature Page

NOTICE OF PRIVACY PRACTICES PATIENT ACKNOWLEDGMENT FORM

Our Notice of Privacy Practices (Notice) provides information about how we may use and disclose protected health information about you. You have the right to receive and review our Notice before signing this acknowledgment. As provided in our Notice, the terms of our Notice may change. If we change our Notice, you may obtain a revised copy.

By signing this form, you acknowledge that you have been informed of our uses and disclosures of protected health information about you for all of the purposes set out in our Notice.

By signing this form, you also acknowledge that a copy of our Notice has been provided to you, that you understand the contents of our Notice and how it applies to you, and that all of your questions regarding the contents of our Notice have been answered.

GLP-1 Injection Consent Form

Emsculpt Intake Form

Emsculpt Neo Treatment Consent

I understand that the treatment may involve risks of complications or injury from both known and unknown causes, and I freely assume these risks. I understand that the treatment over injured or otherwise impaired muscles is contraindicated. I am aware that pregnancy is contraindicated, and pregnant women cannot undergo the treatment
I am aware that EMSCULPT NEO cannot be performed through clothing. I am aware that the applicators must be in full contact with the bare skin. I am aware that as is the case with every heat-based therapy, in rare cases, an occurrence of localized overheating of tissue cannot be excluded.
I am aware that the treatment cannot be applied over the head, heart and neck. I understand that there are certain risks associated with EMSCULPT NEO treatments and they include but are not limited to muscular pain, intramuscular fat decrease, temporary muscle spasm, temporary joint or tendon pain, local erythema or skin redness, increased menstrual flow in female patients and panniculitis*.
I agree to before and after treatment photographs, measurements and weighing, as this will help for medical evaluation of the results of the treatment. Information will be acquired for medical records or marketing purposes.
I understand the results may vary from person to person and that an exact result cannot be predicted. Completing a full treatment series is necessary to maximize treatment efficacy. It is very unlikely, but it is possible that you will not feel any recognizable result after the procedure. I acknowledge the results may not meet my expectations.
I certify that I have read this entire document and that I agree with all provisions. I certify that I have had the opportunity to ask questions and these questions have been answered in full to my satisfaction. I fully understand the treatment conditions, the procedure, and possible side effects. I request and give my consent to be treated with the EMSCULPT NEO by Greg Ratliff, MD / Inject.

IV Therapy Consent Form

Lumecca Consent Form

Lumecca Postop Instructions

Read Lumecca Postop Instructions

Hydrafacial Consent Form

EMTONE Consent

You are scheduled for a series of non-invasive treatments with the EMTONE device. The device is intended for aesthetic procedures.
Your treatment provider will discuss your specific treatment needs. Recommended number of treatments is 4, with sessions separated by at least 3 days. You may need additional treatments depending on the severity of your condition. For optimal results, it is important to follow the treatment plan that has been established for you. The results will typically continue to improve over the next few weeks.
Please arrive at your appointment well hydrated. Ideally, you should hydrate 2 days before, on the day of the treatment, and for 4 days after the treatment. This will result in a more comfortable and efficacious treatment.
On the day of the treatment, you are advised to wear comfortable clothing so the treatment area can be easily accessed. You will be asked to remove any jewelry from the area of interest.
The treatment can only be applied on a body area which is free from hair. It is highly recommended you shave the area on the day of your procedure.
I acknowledge that successful treatment outcome can be affected by smoking or excessive alcohol consumption, as well as: eating disorders, on-going medication, or insufficient hydration. While no special diet is required, you are encouraged to eat healthily to help promote and maintain results.
There is typically no downtime associated with your treatment and there is no anesthetic required. Most patients describe the sensation of the therapy as being comfortable and comparable to that of a pain-free, hot stone massage accompanied by intense mechanical vibrations.
I am aware that pregnancy and nursing are contraindicated, and pregnant women can’t undergo the treatment.
I understand there are certain risks associated with the EMTONE treatments and they include but are not limited to: local erythema, very intense heating sensation or mild pain, dry skin, temporary loss of bodily sensation or itching, hematoma and petechiae. * I understand that the treatment may involve risks of complications or injury from both known and unknown causes, and I freely assume these risks.
I agree to before and after treatment photographs, measurements and weighting, as this will help for medical evaluation of the results of the treatment. Information will be acquired for medical records or marketing purposes.
I understand the results may vary from person to person and that an exact result cannot be predicted. It is very unlikely, but it is possible that you will not feel any recognizable result after the procedure. I acknowledge the results may not meet my expectations.
I certify that I have read this entire document and that I agree with all provisions. I certify that I have had the opportunity to ask questions and these questions have been answered in full to my satisfaction. I fully understand the treatment conditions, the procedure and possible side effects
I have read the above information, and I request and give my consent to be treated with the EMTONE procedure by the physician(s) in the below stated practice and his/her designated staff

EmFace Intake Consent

You are scheduled for a series of non-invasive treatments with the EMFACE®. The EMFACE device used with EMFACE forehead, and EMFACE cheek single use applicators is intended to provide heating for the purpose of elevating tissue temperature for selected medical conditions such as temporary relief of pain, muscle spasms, and increase in local circulation.
Your treatment provider will discuss your specific treatment needs. Four sessions are recommended, with 2–14 days between each session. The typical therapy treatment is generally about 20 minutes. Completing a full treatment series is necessary to maximize treatment efficacy. You may need additional treatments depending on the severity of your condition.
The area of interest should be free from hair. I acknowledge I have been advised to shave the area prior to the procedure or the area will be shaved at the procedure visit.
On the day of the treatment, you are advised to wear comfortable clothing so the treatment area can be easily accessed. Also, the treated area will be wiped with a cleanser before treatment to remove any moisture, perfume, moisturizers, or oils. You will be asked to remove all metallic accessories and electronic devices.
The treatment does not require anesthesia. During the application, you will feel muscle contractions and a heating sensation in the treated area. It is important to note that you should feel comfortable heat, but never feel an unpleasant burning or pain sensation during the treatment. Press the Therapy Discomfort Button any time should you feel any discomfort or pain. The procedure doesn’t require any recovery time. Typically, you can get back to your daily routine right after the treatment.
I am aware NOT TO wear any metallic accessories (such as jewelry, watch or clothes containing metallic threads or metallic accessories) during the treatment. I also acknowledge that I do not have any metallic or electronic implants near the treatment area (such as pacemakers, defibrillators, etc.).

Treatment considerations
I am aware that pregnancy and nursing is contraindicated, and pregnant women cannot undergo the treatment.
I am aware that as is the case with every heat-based therapy, in rare cases damage to natural skin texture (crust, blister, and burn) can occur.
I understand that there are certain side effects associated with EMFACE treatments. The side effects may include but are not limited to erythema, mild swelling, heating sensation, dry skin, temporary damage to natural skin texture (crust, blister, and burn), muscular pain, temporary muscle spasms
I understand that the treatment may involve risks of complications or injury from both known and unknown causes, and I freely assume these risks
I understand the results may vary from person to person and that an exact result cannot be predicted. Completing a full treatment series is recommended to maximize treatment efficacy. It is very unlikely, but it is possible that you will not feel any recognizable result after the procedure. I acknowledge the results may not meet my expectations.
I certify that I have read this entire document and that I agree with all provisions. I certify that I have had the opportunity to ask questions and these questions have been answered in full to my satisfaction. I fully understand the treatment conditions, the procedure, and possible side effects.
I have read the above information, and I request and give my consent to be treated with the EMFACE by the physician(s) in this practice and his/her designated staff.
*For the full range of possible adverse effects and expected device-related treatment sequelae, consult your treatment provider

Morpheus Consent Form

Morpheus Postop Instructions

Read Morpheus Postop Instructions

Skin Pen Postop Instructions

Skin Pen Postop Instructions

Botox Filler Consent

Vi Peel Consent

The VI Peel® contains a synergistic blend of powerful ingredients suitable for all skin types. VI Peel® will improve the tone, texture and clarity of the skin; reduce age spots, improve hyperpigmentation (including melasma), soften lines and wrinkles; clear acne skin conditions; reduce or eliminate acne scars; and stimulate the production of collagen, for firmer, more youthful skin.

Contraindications:
    • Patients who are pregnant or who are breast feeding
    • Patients who have an aspirin, hydroquinone or phenol allergy
    • Patients who have used oral isotretinoin (Accutane) within the past 6 months
    • Patients who have active cold sores, warts, open wounds or history of herpes simplex
    • Patients who are undergoing chemotherapy and or radiation therapy within 6 months
    • Patients with a history of an autoimmune (i.e. Lupus) or liver disease/disorder as well as any condition that may weaken their immune system
The nature and purpose of the treatment have been explained to me. I have read and understand this agreement in its entirety. 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.

MiraDry Consent

miraDry is a non-surgical treatment designed to permanently reduce underarm sweat, odor, and hair with as little as one treatment, in one hour, and with immediate results.
Clinical studies have demonstrated an average reduction of 82% in underarm sweat with two treatments. Like any other medical procedure, results can vary from patient-to-patient.

WHAT YOU CAN EXPECT

SIDE EFFECTS AND RISKS:

Due to the anesthesia, you may experience bruising at the injection site. You may also experience shaking, numbness or tingling in the arm, lasting less than 24 hours.
After the treatment, you may experience swelling, redness, temporary altered sensation, tingling, soreness, weakness, tight banding, pain, or bumps under the skin in the treated area and/or upper arm. In most cases, these side effects will gradually go away. In rare cases, it can last for several months.
Discomfort, tenderness or pain in the underarm is typically treatable with non-prescription medications such as ibuprofen. In rare cases, prescription medications may be needed.
In rare situations, hyperpigmentation (darkening of skin), burns, skin infections, rashes, cysts, numbness/weakness/pain in hand/fingers; and altered sweating in other areas of the body may occur.

RESULTS

Results vary from person to person. You may decide that additional treatments are necessary to achieve your desired outcome. Although highly unlikely, it is possible that you will not experience any noticeable result from the procedure.

MiraDry Post-Op

Read MiraDry Postop Instructions

TRITON Laser Hair Removal Consent Form

TRITON Postop Instructions

Read TRITON Postop Instructions

Pellet Treatment Female Forms

PELLET ACTIVE INGREDIENTS
I understand that (please initial by the appropriate statement):
I am receiving pellets today that contain testosterone only.
I am receiving pellets today that contain estradiol and testosterone
I am receiving pellets today that contain testosterone and anastrozole.
Please initial if you are postmenopausal, have a uterus, and are getting estradiol.
I understand that I have a uterus and am receiving postmenopausal dosing of estradiol. I agree to take progesterone as directed by my health care provider while receiving estradiol.

Biote Female Paperwork - What Might Occur

Pellet Treatment Male Forms

What Might Occur After A Pellet Insertion (Male)

Microneedling Consent Forms

MICC/Lipo Mino Shot Consent

Post-Insertion Instructions For Men

Post-Insertion Instructions For Women

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