Skin Care & Injectable Consent Form

Required *

Client Contact Information

Email *

Client's First Name *

Middle Name

Client's Last Name *

Sex *

Female Male

Date of Birth * (mm/dd/yyyy)

Cell Phone *

Street Address *

City *

State *

Zip *

Referred by *

Facebook Friend Google Groupon Other

Is this a Groupon Promotion? *

Yes No

Medical History

Please answer all questions honestly. This information is essential for your safety and helps us provide you with the best possible care.

Allergies & Hypersensitivity

Question	Yes	No
Have you ever had a severe allergic reaction to any medication or product?
Are you allergic to lidocaine or other local anesthetics?
Are you allergic to latex?
Do you have any known allergies to skincare products or ingredients?

Neurological Conditions

Question	Yes	No
Do you have any neurological disorder?
Have you ever had Bell's Palsy or facial paralysis?
Do you have Myasthenia Gravis?
Do you have ALS (Amyotrophic Lateral Sclerosis)?
Do you have Lambert-Eaton Syndrome?

Bleeding & Bruising

Question	Yes	No
Do you have a bleeding or clotting disorder?
Are you taking blood thinners (Warfarin, Heparin, Eliquis, etc.)?
Have you taken aspirin, ibuprofen, or NSAIDs in the past week?

Skin Conditions

Question	Yes	No
Do you have any active skin infection in the treatment area?
Do you have a history of cold sores (herpes simplex)?
Do you have a history of keloid or hypertrophic scarring?
Do you have eczema, psoriasis, or rosacea?
Do you have active cystic acne in the treatment area?

Autoimmune Disorders

Question	Yes	No
Do you have any autoimmune disorder?
Do you have Lupus (SLE)?
Do you have Rheumatoid Arthritis?
Do you have Scleroderma or similar connective tissue disorder?

Cardiovascular

Question	Yes	No
Do you have any heart disease or heart condition?
Do you have high blood pressure?
Have you ever had a stroke or TIA?

Diabetes & Metabolic

Question	Yes	No
Do you have diabetes?
If diabetic, is your blood sugar well controlled?

Infections & Immune System

Question	Yes	No
Do you have HIV/AIDS or Hepatitis B/C?
Are you immunocompromised or on immunosuppressive medications?

Cancer History

Question	Yes	No
Have you ever been diagnosed with cancer?
Have you ever had skin cancer?
Are you currently undergoing or have recently completed chemotherapy or radiation?

Previous Treatments

Question	Yes	No
Have you had Botox or neurotoxin injections in the past 2 weeks?
Have you had dermal filler injections in the past 2 weeks?
Have you had facial surgery in the past 6 months?
Have you had dental work in the past 2 weeks?

General Health

Question	Yes	No
Are you pregnant?
Are you breastfeeding?
Are you trying to conceive?
Have you taken Accutane (isotretinoin) in the past 6 months?
Are you currently using prescription retinoids (Retin-A, Tretinoin)?

If you answered "Yes" to any questions above, please provide details:

Are you presently taking any medications? If yes, list below: *

Allergies *

I certify that I have disclosed all relevant medical conditions and the information provided is accurate to the best of my knowledge. *

Injectable Treatment Consent and Waiver

Important: Voluntary Consent for Injectable Treatment

I understand that Botox, dermal fillers, and other injectable treatments are ELECTIVE and COSMETIC procedures. They are NOT medically necessary.

I am choosing to undergo this treatment voluntarily, of my own free will, and without any pressure or coercion from Celebration Aesthetic Center or its staff.

I have been given the opportunity to ask questions and have received satisfactory answers. I understand the risks, benefits, and alternatives to this treatment.

Botox / Neurotoxin Information

Botox and other neurotoxins work by temporarily relaxing the muscles that cause wrinkles. Results typically appear within 3-7 days and last 3-4 months. The procedure involves small injections into targeted facial muscles. This treatment is FDA-approved for cosmetic use and has an excellent safety profile when administered by trained professionals.

Dermal Filler Information

Dermal fillers are injectable gels used to restore volume, smooth wrinkles, and enhance facial contours. Results are immediate and can last 6-18 months depending on the product used and treatment area. Hyaluronic acid fillers can be dissolved if needed. All our fillers are FDA-approved products.

Potential Risks and Side Effects

While injectable treatments are generally safe, potential risks include:

Bruising, swelling, redness, or tenderness at injection sites
Swelling and tenderness (typically resolves in 1-3 days)
Redness or mild discomfort at injection sites
Asymmetry or uneven results
Infection
Allergic reaction
Product migration from injection site
Vascular occlusion/tissue necrosis (rare but serious)

Please confirm the following acknowledgments *

I confirm that this is an ELECTIVE procedure and I am proceeding VOLUNTARILY, fully understanding that it is not medically necessary. I understand the potential risks and complications associated with injectable treatments and have had the opportunity to ask questions. I understand that results vary and are not guaranteed. Touch-up treatments may be needed to achieve optimal results. I agree to follow all aftercare instructions provided and to contact the clinic immediately if I experience any concerning symptoms.

Disclosure and Signature

No Show or Late Fee Policy

Appointment Confirmation: All customers must confirm their appointments 24 hours in advance via the web appointment application. Failure to confirm the appointment may result in the appointment being cancelled.

Credit Card on File: All customers must have a credit card on file. This credit card will be used to charge any applicable no-show or late fees.

Cancellation/Rescheduling: Celebration Aesthetic Center requires a minimum of 24 hours' notice to cancel or reschedule a visit. Cancellations or reschedule requests must be submitted by calling (321) 939-1093 or calling Vanessa at (786) 382-4186.

No-Show Fees: Customers who fail to show up for their scheduled appointment (a "no-show") will automatically be charged the full cost of the scheduled treatment.

We thank you for your cooperation with this policy. Adhering to the 24-hour cancellation/rescheduling window and maintaining a credit card on file helps us to efficiently manage our schedule and provide timely care to all of our clients. Please let us know if you have any other questions.

Photo and Video Consent

We may take photos before, during, and after your treatment for documentation purposes. Please select your preference:

Treatment Records Only I consent to anonymous use (no face/identifying info) for marketing and educational purposes I do not consent to any photos being taken

Release and Indemnification

I recognize that there are certain inherent risks associated with the above-described treatment and I assume full responsibility for personal injury to myself. In exchange for such treatment, I hereby fully release and forever discharge Celebration Aesthetic Center (including its officers, members, owners, employees and agents) from any and all damages, costs, expenses, liabilities, causes of action, claims and demands, of whatever character, in law or in equity, whether known or unknown, direct or indirect, asserted or unasserted, and whether or not on account of myself, Celebration Aesthetic Center or other third parties, or in any way arising out of the above described treatment I have requested Celebration Aesthetic Center perform. It is the intention of the parties that this agreement binds all parties whose claims may arise out of or relate to the treatment or services provided by Celebration Aesthetic Center including any spouse or heirs of the client/patient and any children, whether born or unborn. Any legal or equitable claim that may arise from participation in the treatment shall be resolved under Florida law. I agree to indemnify, hold harmless and defend Celebration Aesthetic Center (including its officers, members, owners, employees and agents) against all third-party claims, causes of action, damages, judgments, costs or expenses, including attorneys' fees and other litigation costs, which may in any way arise from the above described treatment I have requested Celebration Aesthetic Center perform.

Arbitration Agreement

It is understood that any dispute arising as to malpractice of the Skin Care treatment shall be decided by a neutral arbitrator. Any arbitration proceeding will be governed by Florida arbitration statute, the fees for the arbitrator will be split pro-rata among the parties and each party will be responsible for their own attorneys' fees and costs. Any action to collect fees from the client/patient for the treatments performed may be brought in any court located in Florida and the prevailing party in such collection action shall be entitled to recover its reasonable attorneys' fees and costs. Filing of any action in any court to collect any fee from the client/patient shall not waive the right to compel arbitration of any malpractice claim.

Communication Preferences

I consent to receive appointment reminders, aftercare instructions, and promotional offers via email. I consent to receive appointment reminders and important notifications via text message.

I, the applicant for this form, warrant the truthfulness of the information provided in this form.

Electronic Signature * (Please type your First and Last Name)

Today's Date *

Agree *
I understand that typing my First and Last name above constitutes a legal signature confirming that I acknowledge and agree to the Terms above.