Health History
Please tap Yes or No for each question.
If yes to an important event in the next 2 weeks, please explain:
If yes to previous cosmetic treatments, which treatment, where, and when?
Current medications, vitamins, and supplements (please list all):
Please list any other medical conditions, surgeries, or anything else we should know:
Informed Consent for Treatment
Please read this carefully. Ask any questions before signing — Esteban will explain your treatment, the expected results, and the risks during your consultation. Do not sign until you understand and agree to the treatment.
What to Expect
Your provider will discuss what the treatment does, how many sessions are typically recommended, and what results are realistic for you. Results vary from person to person, and no specific result can be guaranteed. Some treatments work gradually over days or weeks, and more than one session may be recommended for the best result.
Possible Risks and Side Effects
Common, usually temporary: pain or tenderness, redness, swelling, bruising, itching, and small bumps at the treatment or injection sites. Less common: infection, scarring, changes in skin color (lighter or darker areas), allergic reaction, asymmetry, lumps or nodules, and results that are not as expected, which may need additional treatment to correct.
Treatment-specific risks include:
Neurotoxin (Botox): temporary drooping of an eyelid or brow, headache, or uneven muscle movement, which resolves as the product wears off. Results usually appear in 3–7 days and last 3–6 months. Before treatment, avoid blood thinners and certain supplements for 5–7 days and alcohol for 24–48 hours unless your provider tells you otherwise. After treatment, do not rub or press the treated area for 24 hours, and avoid lying face down or intense exercise for 24–48 hours.
Dermal fillers: lumps, migration of product, and — rarely — blockage of a blood vessel (vascular occlusion), which can damage skin or, very rarely, affect vision and requires urgent treatment. Tell us immediately about severe pain or skin color changes after treatment.
Microneedling / PRP: skin irritation, pinpoint bleeding, flare-up of cold sores, and temporary increased sensitivity. PRP involves drawing a small amount of your own blood, concentrating the platelets, and injecting them into the treated area. Pigment changes and small scabs can occur, and more than one session may be needed.
IV therapy: bruising or irritation at the IV site, lightheadedness, and a small risk of infection. Vein irritation, fluid overload, electrolyte imbalance, and nausea can also occur. IV therapy is a complementary treatment and does not replace medical care from your primary healthcare provider.
PRP + collagen threads (under-eye): swelling, bruising, and temporary visibility or unevenness of threads under the skin.
My Acknowledgments — Please Confirm Each Line
Tap each box to confirm you have read and agree to that line.
Release of Liability
By signing below, I release AZSkinLab, Esteban Peralta, NP, and their employees and representatives from any claims, damages, injury, loss, or expenses that may result from my treatment, including complications or results not as expected.
I have read and agree to the Release of Liability above. Photograph Consent
Clinical record photos are required before any procedure: before/after photos are kept in my file for treatment records and are not shared without my separate consent. If I refuse photos, my treatment may be delayed.
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