Client Intake
Please fill out the following form in order to participate in our services.
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
DERMAL FILLERS
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: \
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Post treatment discomfort, swelling, redness, and bruising
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Post treatment bacterial, viral, and/or fungal infection requiring further treatment
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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.
