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Revived Body - Mobile IV Therapy & Aesthetics
Dermal Filler Waiver

All customers must complete this waiver before receiving a Dermal Filler aesthetic service from Revived Body. 

Client Intake 

Please fill out the following form in order to participate in our services.
Have you had Dermal Filler in the past? (check box)
Medications (check any that apply)
Supplements (check any that apply)

Please check any conditions that apply to you:

Authorization to Release Photographs

I authorize Revived Body to release any and all photographs taken for the following uses: social media, office photo gallery, submission for educational purposes.

I understand that I will not be identified by name in these photographs. Every attempt will be made to cover-up or remove identifiable features (such as tattoo); however in some circumstances, the photograph may portray features which make my identity recognizable.

** your decision to release the photographs will not affect your treatment **

Client Consent

Proposed Treatment
Dermal Filler is a gel of hyaluronic acid generated by streptococcus species of bacteria, chemically cross linked with BDDE, stabilized and suspended in a physiologic buffer at PH=7 and concentration of 20 mg/ml. Some Dermal Filler products may have Lidocaine added for comfort . Areas most frequently treated are: Nasolabial folds, Oral commissures, Lips, and Glabellar. Clients may experience a slight burning sensation during injections.
Anticipated Benefit

The procedure takes about 30-45 minutes. Results last approximately six months to 1 year.

Risks, complications and others:

There are certain inherent and potential risks and side effects in any invasive procedure and in this specific instance such risks include but are not limited to: \

  • Post treatment discomfort, swelling, redness, and bruising 

  • Post treatment bacterial, viral, and/or fungal infection requiring further treatment 

  • Allergic reaction

Please read the following statements carefully. By signing below, I hereby:

Agree to cooperate fully with my Nurse Injector’s recommendations while under treatment, realizing that any lack of cooperation can result in a less-than-optimal result.


Understand that my Nurse Injector can’t promise that everything will be perfect. I understand the reasons for the proposed treatment and potential benefits to me; it has been explained to me what alternatives there are, if any, to this treatment. I have given a complete and truthful medical history, including all medicines, drug use, pregnancy, etc. I certify that I speak, read and write English. All of my questions have been answered before signing this form and I am willing to undergo this elective treatment.


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