Russian Lips Name * First Name Last Name Phone * (###) ### #### Date of Birth * Date of birth * MM DD YYYY Email * Please read and initial each of the statements below: I understand that Micro-needle Lip Hydration fillers are sterile inject-able materials consisting mainly of: Hyaluronic acids, or Hydroxyapatite molecules with or without lidocaine (numbing solution). * I understand that these are non-permanent, and metabolized by the body. * I understand that filler injections are given to temporarily correct facial wrinkles, lines, folds, or scars, and/or for lip augmentation, and/or for replacement of volume to the face, cheeks, orbital rims, nose, temples, etc. * I understand that some fillers above have been approved by the FDA (Food and Drug Administration) for correction of facial wrinkles or lines, or for lip augmentation or for cheek augmentation (“on-label” use), however, most fillers are also used “off-label” for the lips, eyelids, nose, cheeks, temples and/or other facial cosmetic corrections. * I understand that the safety and effectiveness of treating facial areas “off label” has not been studied; however, fillers have been extensively used in all areas of the face. * I understand that there are alternatives to filler injections, including no treatment, collagen or fat injections, or other facial soft tissue augmentation or implants, as well as cosmetics, Botox, laser skin resurfacing, chemical peels, or plastic surgery for wrinkle reduction. * I understand that the actual degree of improvement cannot be predicted or guaranteed. * I understand that the effect will gradually wear off and additional treatments are necessary to maintain the desired effect. * I understand that results depend on the filler as well as the amount or volume of the filler. * I understand that Using multiple syringes often results in more dramatic improvement of wrinkles. * I understand that I am responsible for the cost of each filler syringe and treatment without any guarantee of results. * I understand that side effects and complications include but are not limited to: potential allergic reaction, a lumpy or “thick” feeling at or just under the skin, bruising, hematoma, redness, discoloration, induration, scars, vascular occlusion, itching, pain, nerve damage, infection, over-correction, granulomas, palpable or visible material, blindness, tenderness, swelling, asymmetry, or shifting can occur. * I understand that injections into the lip area could trigger a recurrence of facial cold sores (Herpes simplex infections) for patients with a history of prior cold sores. * I understand there is no guarantee of the results of any treatment. I understand the regular charge applies to all subsequent treatments. 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 understand that the majority of humans have facial asymmetry and therefore perfect symmetry is unrealistic in most cases. * I understand that due to the potential for an allergic reaction, fillers are not recommended for patients with severe allergies or a history of anaphylaxis to components of the particular filler. * I understand the risk of bruising or bleeding may be increased by medications with anticoagulant effects, such as aspirin and non steroidal anti-inflammatory drugs (e.g., Ibuprofen, Aleve, Motrin, Celebrex), high doses of Vitamin E, and certain herbal supplements and foods (Ginkgo Biloba, St. John’s Wart, Flaxseed, nuts, fish oil, Omega-3, etc). * I understand that fillers should not be administered to a pregnant or nursing woman. * I understand there is no guarantee of the results of any treatment. I understand the regular charge applies to all subsequent treatments. 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 consent to allow Desireecejasymas to consult with and evaluate me in order to determine if am a good candidate for Micro-needle lip hydration infusions. I understand that photographs will be taken and kept in my file. I agree that these forms have been completed truthfully and to the best of my knowledge and abilities. I understand the contraindications and possible side effects of injections as discussed with staff members of Desireecejasymas. Furthermore, I agree to waive all liabilities toward Desireecejasymas for any injury or damages incurred due to my misrepresentation of my health history.by signing below you agree that:I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. I agree I will assume the risk and full responsibility for any and all injuries, losses, side effects, or damages which might occur to me while I am undergoing this procedure. I do not hold Desireecejasymas Inc , 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 grant Desireecejasymas inc permission to take and use photos/videos of me for marketing and promotional purposes, including social media, advertising, and print materials. I understand I will not receive compensation and waive any rights to the images. * CLIENT'S SIGNATURE: Thank you!
