Client Intake
Please fill out the following form in order to participate in our services.
Please check any conditions that apply to you:
Client Consent for Neuromodulators
(BOTOX / DYSPORT / JEUVEAU / XEOMIN)
Proposed Treatment
Neuromodulators (AKA BOTOX/DYSPORT/JEUVEAU/XEOMIN/etc.) is Botulinum Toxin Type A (so called as Miracle Poison), a substance has been used for more than a decade to improve spasm of the muscles around the eye, to correct double vision due to muscle imbalance as well as numerous other neurological uses. BOTOX/DYSPORT/JEUVEAU/XEOMIN Cosmetic is now approved by the FDA to improve the appearance of the vertical lines between the brows. A few tiny injections of BOTOX/DYSPORT/JEUVEAU/XEOMIN Cosmetic relax overactive muscles and soften those vertical lines. As such, it may be used to temporarily relax certain facial muscles, thus having a cosmetic effect by smoothing certain facial wrinkles (“Crow’s feet” and other lines of expression).
Anticipated Benefit
The effect of Neuromodulators begins in a few days and lasts from 2- 6 months, at which time retreatment is necessary to gain a similar muscle relaxant effect. Occasionally, “touch-up” injections may be required for full effect.
Neuromodulators works best for "dynamic" lines and wrinkles (lines in motion), and is less effective for fine textural changes on the skin surface and for "static lines" (lines present at rest). It is a temporary treatment, meaning it will have to be repeated on a regular basis to remain effective.
Contraindication of Treatment
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Pregnant or lactating women
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Clients with allergies to egg, human albumin.
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Severe infection, inflammation, (including acne), or dermatitis of areas to be injected
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Facial asymmetry such as Bell's Palsy
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Clients with neurological disorders including Lou Gherig's, myasthenia gravis, multiple sclerosis, Parkinson's disease.
Risks, complications and others:
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Allergic reactions, including rash, itching, local swelling, or more severe reactions.
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Neuromodulators contains albumin from human blood, to which certain individuals are allergic. If you have had adverse reactions to certain immunizations or are allergic to eggs, you should not use Neuromodulators.
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Because Neuromodulators contains human albumin, there is a remote chance of transmission of serious viral diseases. This complication has never been identified, but it is possible.
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Bruising may be possible, especially if Neuromodulators is used around the eye area. Typically, these discolored areas disappear with time.
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If used around the eye, Neuromodulators may cause difficulty in closing eyelids tightly. The result may be corneal exposure with resultant drying, potential ulceration and visual complications. The affected eyelid may droop. Protective patching and/or medication may be required until this complication has passed.
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The safety of Neuromodulators in pregnant women or nursing mothers has not been established.
Client Consent For 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 Benefits:
These treatments can help reduce the appearance of fine lines and wrinkles, restore volume to areas that may have lost elasticity over time, and improve the overall texture and hydration of the skin.
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
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.
Non-Refund Policy
I acknowledge and understand that all fees paid for Neuromodulators (e.g., Botox) and Dermal Filler treatments provided by Revived Body are non-refundable. Once payment has been made, there will be no refunds or reimbursements, regardless of the outcome, my decision to discontinue the treatment, or any other circumstances. I consent to this non-refund policy and agree to abide by it.
Provider's Right to Use Alternative Brands:
I acknowledge and grant the Injectors at Revived Body, the right to use alternative brands of neurotoxin (including but not limited to Botox, Jeuveau, Xeomin, Dysport, etc.) and Dermal Fillers (including but not limited to Restylane, Juvederm, Radiesse, RHA, etc.) during my treatment. I understand that the choice of specific brands may be based on clinical considerations, product availability, and the injector's professional judgment. I consent to this flexibility and trust the injector's expertise in selecting the most suitable products to achieve the desired outcome. This authorization extends to both initial and follow-up treatments. I have been provided with the opportunity to ask questions and have had my concerns addressed to my satisfaction.
Acknowledgment of Treatment Understanding and Cooperation Agreement
Agree to cooperate fully with my Injector’s recommendations while under treatment, realizing that any lack of cooperation can result in a less-than-optimal result.
Understand that my 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.
