Informed Consent and Acknowledgment of Risk

I, the undersigned, hereby consent to the Viva La Skin treatment(s) I have discussed with the provider. I understand the nature and purpose of the procedure(s) being performed, and I acknowledge that I have had the opportunity to ask questions and receive clear, understandable answers to all of my concerns regarding the treatment(s). Although it is impossible to list every risk and complication, I have been informed of possible benefits, risks, and complications.

I understand that there are potential risks associated with the procedure(s), which may include, but are not limited to, the following:

Swelling, bruising, or redness at the treatment site.

Pain, tenderness, or discomfort at or around the treated area.

Infection and other complications from the procedure, including the possibility of scarring or hyperpigmentation.

Allergic reactions to substances such as Botox, dermal fillers, numbing agents, adhesives, etc.

Temporary or permanent changes in skin tone or texture.

Unsatisfactory results or need for additional treatment to achieve desired results.

Nerve injury, particularly in areas with sensitive or thin skin.

I acknowledge that individual results may vary, and there is no guarantee that I will achieve the specific outcomes I expect. I understand that multiple treatments may be necessary to achieve the optimal results, and some procedures may require touch-ups or follow-up appointments.

I am aware that the success of these treatments depends on many factors, including but not limited to, my general health, skin type, and the nature of the procedure. I agree to follow all post-treatment care instructions provided by the provider to minimize risks and complications.

I acknowledge that if any complications arise, I will promptly notify the medical spa staff and may seek further care, including emergency medical treatment if necessary.

By signing below, I confirm that I have read and understood the potential risks associated with the procedure(s) being performed. I voluntarily agree to proceed with the treatment(s), fully aware of the risks involved.

HIPAA Acknowledgment and Consent:

I, the undersigned, consent to the use and disclosure of my protected health information (PHI) for the purposes of treatment, payment, and healthcare operations as outlined in Viva La Skin’s Notice of Privacy Practices. I understand that:

1. My PHI may be used for treatment, billing, and administrative purposes.

2. My PHI may be shared with third-party providers or insurance companies for payment processing.

3. I have the right to access, correct, or request restrictions on my PHI at any time.

4. I may revoke this consent in writing, except where actions have already been taken based on it.

I have received the Notice of Privacy Practices and understand my rights under HIPAA.