Consent for Aesthetic Procedures Form

First Name

Last Name

Date of Birth

Select procedure(s):

This is an informed consent document that has been prepared to help inform you of your nonsurgical aesthetic procedure(s), its associated risks and alternative treatments. It is important that you read this information carefully and completely. Please read each word, sentence, paragraph, and page. Please initial each section and sign the consent for aesthetic procedure(s). I voluntarily consent to and authorize Bodika cosmetic Med Spa a and all associated physicians, licensed aestheticians and other healthcare providers as deem appropriate, to treat my condition which has been explained to me as: understand that the following non- surgical aesthetic-procedure(s) is planned for me, and I voluntarily consent, request and authorize this procedure(s):

MicroneedlingPRPPRP Hair RestorationBotoxNon-Surgical Double Chin FillerThreading

Dermal FillersLaser Hair RemovalEmage Facial AnalysisHydro DermabrasionSkin CarePlastic Surgery

Ultrasound CavitationCellumaIV therapyNLPcontouraThermage FlxYoga, REIKI & Hypnotherapy

I understand the treatment may involve risks of complications or injury from both known and unknown causes and I freely assume these risks. Possible risks include but are not limited to scarring, skin redness, skin irritation, discomfort, tenderness, pinpoint bleeding, bruising, pimple-like bumps, dry skin, lightening of the skin (hypopigmentation), and darkening of the skin (hyperpigmentation). I understand these stated risks are those most relevant to an intelligent decision on my part, and the list of remotely possible material risks is nearly unlimited. I agree to adhere to all safety precautions and regulations during the procedure.
Acknowledged

I agree to allow photographs of the intended procedure site for diagnostic purposes and to enhance my medical record to follow progression of my treatment.
Acknowledged

I agree that these photographs will remain the property of Bodika cosmetic Med Spa.
Acknowledged

I understand that my responsibility, as the patient, is to follow the post- procedure care instructions and to maintain regular office visits that are critical to the success of the procedure. I agree that I will notify Bodika cosmetic Med Spa as soon as possible of any questionable conditions, complications, unusual symptoms or any questions that can arise.
Acknowledged

I understand that I have the right to refuse treatment.
Acknowledged

I agree to pay for the above mentioned procedure and understand that there will be no refund. I also understand that subsequent revisional procedures will require additional costs.
Acknowledged

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