Client Consent Form

Before filling out the consent form please download the disclosure information that pertains to your elected procedure

I agree to the use of Digital Electronic Signatures on this form below. I understand that all of my answers will be electronically sent to Heartbreaker Lips and Aesthetics and will be digitally logged as a legal representation of my agreement to the terms *

YES, I agree to the use of electronic signatures.
I DO NOT UNDERSTAND WHAT AN ELECTRONIC SIGNATURE IS (if you choose this answer, do not continue. Please call 909-362-3082 for explanation)

Today's Date *

First Name *

Last Name *

Date of Birth *

Phone Number *

Email address *

Complete Address *

I, as a client, I have requested that The technician of Heartbreaker Lips and Aesthetics to describe the procedure I have elected to have done so that I may make an informed decision whether or not to undergo the following checked procedure. *

Plasma Fibroblast
Hyaluron Pen Filler
Brow Lamination
Brow Tint
Lash Lift
Lash Tint
Fat Dissolver

I have been informed about the chosen procedure and have had the opportunity to ask questions and have read the information provided me on the website, I understand fully the pros and cons or side effects of the procedure I am electing. - Initial *

I hereby authorize the technician of Heartbreaker Lips and Aesthetics to take photographs of the work performed both before and after treatment, and I further authorize the use of said photographs to be used for the purpose of advertising.- Initial *

I hereby authorize the technician of Heartbreaker Lips and Aesthetics to take photographs of the work performed both before and after treatment to be maintained only in file.- Initial *

I have informed the technician of Heartbreaker Lips and Aesthetics that I am in good health and not under the care of any physician. (If NO give deails on health questionair below) - Choose One *

Yes
No

I have been made aware that there may be known and unknown risks and hazards related to the performance of the procedure planned for me and I understand that no warranty or guarantees have been made to me as to the results. - Initial *

I acknowledge that obtaining this procedure is my choice alone. The application of the procedure will result in a permanent change to my appearance, and that No representations have been made to me as to the ability to later restore the skin - Initial *

I am not pregnant or nursing. I do not have any history of herpes infection at the proposed procedure site. I do not have epilepsy, diabetes, allergic reaction to latex or antibiotics, hemophilia, bleeding disorder. or cardiac valve disease. - Initial * *

If I suffer from any blood borne pathogen disease, or any other communicable disease, I have informed the technician of and have been advised of any medications and procedure necessary for proper healing from my elected procedure- Initial *

I have advised the technician of Heartbreaker Lips and Aesthetics of any allergies to latex gloves, soap, or medications. I acknowledge it is not reasonable for the technician to determine whether I might have an allergic reaction. - Initial *

I acknowledge infection is always possible as a result of any procedure, and I agree to follow all aftercare instructions. If infection occurs I will notify the technician, and my physician. - Initial *

I understand my technician will use appropriate instruments and sterilization techniques. I have been informed of how long my procedure takes to heal. - Initial *

I understand that inks, dyes, pigments, plasma fibroblast, hyaluron pen and fat dissolvers have not been approved by the FDA and that the health consequences of using these products are unknown.- Initial *

I have been made aware that this procedure may involve pain and discomfort and my technician may apply numbing cream as needed. - Initial *

I have been made aware that a follow up procedure may be required. - Initial *

I accept full responsibility for any and all, present and future, medical treatment(s) and expenses I may incur in the event I need to seek treatment(s) for any known or unknown reason associated with the procedure planned for me. - Initial *

I agree, should I have a discrepancy of any kind. I shall first notify my technician of Heartbreaker Lips and Aesthetics *

I agree to release and hold harmless, the technician, management and owners of Heartbreaker Lips and Aesthetcis from all claims of negligence, damages, or legal actions arising my elected procedure - Initial *

I have been told,read, downloaded or handed a copy of the aftercare instructions. I fully understand them and agree to follow them for proper healing from my procedure - Initial *

Medical history form for: (Your full name) *

Person to contact in an emergency (Contacts name) *

Emergency contacts phone number *

Are you now or have you been under the care of a physician within the last two years? *

Yes
No

If YES please describe. If NO type N/A *

Physicians Name *

Physicians Phone Number *

Physicians Address *

List all medications you are currently taking, including Retin A, Glycolic Acid and Acutane: * *

List any drug, makeup, skin or food allergies (i.e., soaps or cleansing creams): *

Have you recently undergone a skin peel? * *

Yes
No

What products do you use for skin care? * *

I agree if a dispute over this contract shall arise it shall be settled by arbitration in the state of California in accordance with the Rules of the American Arbitration Association and judgment of the award rendered by the arbitrator(s) may be entered i *

By Typing Full Name, you agree under penalty of perjury that: I am over the age of 18 years of age, I have answered all questions truthfully, I understand and have been informed of the procedures and risks. I am electing to have the procedure. I agree to *

Technicians Name: Nichole Wray? *

Yes
No
Other

By submitting this consent form you are indicating you have been informed about the procedure you are elected to have done. Mark yes or no *

Yes
No

Plasma Fibroblast Disclosure and Before and Aftercare protocol

HLP Plasma Fibroblast Disclosure Before And After Protocol

PDF – 472.5 KB 163 downloads

Download

Hyaluron Pen Lip, Wrinkle Filler and Fat Dissolver Disclosure and Before and Aftercare protocol

HLP Hyaluron Pen Filler Fat Dissolveer Disclosure

PDF – 739.6 KB 173 downloads

Download