Patient’s Consent Form

Treatment name:

Location treated:

Date of last treatment:

(ii) Filler (i.e. juvederm® or Sculptra®) within the last 3-6months
YN

Treatment name:

Location treated:

Date of last treatment:

(iii) Neurotoxin (i.e. Botox® or Dysport®) within the last 3-6months
YN

Treatment name:

Location treated:

Date of last treatment:

(iv) Ablative resurfacing laser treatment
YN

Treatment name:

Location treated:

Date of last treatment:

(v) Non-ablative resurfacing laser treatment
YN

Treatment name:

Location treated:

Date of last treatment:

(vi) Dermabrasion or deep facial peels
YN

Treatment name:

Location treated:

Date of last treatment:

(vii) Lipoplasty in the face or neck regions radio radio-256 label_first default:1 "Y" "N"]

Treatment name:

Location treated:

Date of last treatment:

(viii) Facelift or blepharoplasty or brow lift
YN

Treatment name:

Location treated:

Date of last treatment:

Are you currently taking the following prescription medications:

1. Accutane within the last 12 months:

2. Anticoagulants or anti-platelet drugs:

3. Immunosuppressant drugs:

List all medications or supplements below. Be sure to include all prescription or non-prescription medications. If you are not taking any medications or supplements, please check here: Not any