Booking – gozzanny beauty and wellness

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Patient Information and medical history

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Name *

Date

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

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Phone *

Email *

Age

Phone (copy) *

Date of birth

Sex

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Diabetes

Hepatitis

Herpes

Menopause

Sensitive to anesthetic

Lupus

Are you under the care of a physician

Irregular Menses

Heart Problems

Hysterectomy

Hypertension

Photosensitive disorder

Autoimmune illness

Current / Recent medications

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Keloid Scars

If yes, Please Explain

Skin Cancer

Please Explain

Electrolysis

Please explain

Skin Infections

Please explain

Use of acne products / drugs

Please explain

Chemical peels

Please explain

Laser work of any type

Please explain

Allergies of any kind include drugs

Type of treatment requested Botox / Filler

Hives

Please Explain

Waxing

Please Explain

Hypersensivity to skin products

Please explain

Tanning within the last 6 weeks

Please explain

Laser skin resurfacing

Please explain

Photo sensitizing substances

Please explain

Medical Illness

Are you pregnant?

Areas of interest aesthetic treatment

I attest the above information to be true, knowing my provider relies on this information to provide safe and affective treatment.

Patient Signature

Date

5. I also certify that I have none of the known conditions that would contraindicate treatment. These conditions include hypertrophy scars, a history of any autoimmune disease, or immune therapy. I am not pregnant, breast-feeding, and I have no known allergy to Botox.

6. I certify that I have read this entire informed consent and that I understand and agree to the information stated in this form. I certify that I am a competent adult of at least 18 years of age, or that if I am a minor under the age of 18, I understand that the consent of my parent/legal guardian will also be required before treatment. This informed consent is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assigns. I agree that any picture taken of my treatment site may be used for publication and teaching purposes, however, my name will not be disclosed and complete confidentiality of my name will be maintained.

7. No guarantee, warranty or assurance has been made as to the treatment results

8. I understand that the results are of temporary nature, and more treatments will be needed to maintain improvement. I agree to adhere to all safety precautions described here including:

* No laying down or reclining for four hours after injection
* No scratching or rubbing the injected area
* No bending forward for four hours
* Make up should be avoided for one to two hours after injection

9. I agree to pay for the above mentioned services.

Patient Name

Signature with date

Witness Signature with date

Appointment Date and Time

Date

Time

MARKETING AND EDUCATIONAL CONSENT:

MARKETING AND EDUCATIONAL CONSENT:

I grant my permission for the use of photographs, videos, and case information for the following purposes:

I understand that these photographs, videos, and case information may be published by Gozzanny Beauty and Wellness and /or any party acting under their authority or license in any print, visual or electronic media including, but not limited to, presentation, teaching courses, training manuals, magazines, websites, and social media, for the commercial, non profit, or educational purposes of informing others about non-surgical aesthetic treatment procedures.

I release and discharge Gozzanny Beauty and Wellness and all third parties acting under their authority and license from all rights that I may have in the images, and from any claim I may have in such use in publication, including any claim for payments in connection with publication of the images.

I understand that in some circumstances, the images may portray features that can make my identity recognizable.

I understand that I have the right to revoke this consent in writing at any time, but in doing so, it will not have any effects in any actions taken prior to the revocation.

I certify that I have read all the above policies and all my questions and concerns have been addressed and answered to my satisfaction.

Patient’s Name *

Patient’s Signature

Date