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Disclosure of Medical History- I agree that I will disclose a full and accurate personal medical history, including any and all information regarding medical conditions and my use of medication, drugs, herbs, vitamins or other supplements of any kind. I understand that failure to do so may affect my treatment outcome and increase the likelihood or severity of complications.

Confidentiality- I understand that no information regarding services performed shall be released without my express consent except as follows: I authorize that copies of my records may be sent to another location if I seek additional treatment at that location. I understand that, in addition to authorized clinic personnel, the clinic's medical director and consulting physicians shall have full access to my treatment records. I understand that appropriate medical review may be conducted to further the safety and efficacy of my practitioners services. I understand my practitioner may also provide limited patient information to various third-party vendors to provide database development and maintenance services, revert referral services or marketing research services. I understand that photographs may be taken to document treatment results, but they will not be released or used or otherwise without my specific written consent. My practitioner will maintain file copies of all records for a minimum of three years.

Skin Care Products- I understand that some of the skin care products offered by my practitioner are professional strength and formulated to aggressively treat problem skin. I agree that I will use any skin care products obtained for the clinic in accordance with instructions and directions provided to me by the clinical staff and only after becoming acquainted with the product and its recommended use. I realize that I may experience varying degrees of discomfort, redness, burning, peeling, itching, dryness or other symptoms, especially in the early stages of use. These symptoms should lessen and eventually subside as my skin tolerance develops. I understand that in unusual circumstances, use of these professional strength products could be harmful and even cause injury to the skin (infection, discoloration, superficial scarring, etc.) . I will discontinue use and notify my practitioner if any unusual or concerning irritation occurs. I will not use any of these professional strength products if I am nursing, pregnant or trying to become pregnant. I understand that long-term use is necessary to achieve and retain the desired benefits.

Photography- I understand that portraits of myself are required for HIPAA compliant and recordkeeping. And by refusing such I am therefore refusing treatment. I also understand that my photos will not be released or posted on social media platforms without additional consent.

Nitrous Oxide Consent- (Nitrous oxide, also called laughing gas, is a colorless, slightly sweet gas that is used during some treatments for relaxation and anxiety relief. When inhaled it can induce feelings of euphoria and sedation. It can also produce sensations of drowsiness, warmth, and tingling in the hands, feet and or about the mouth. You will be able to swallow, talk and cough as needed.) I understand the potential side effects and know that the effects wear off rapidly and will not leave the office until my head feels clear.

Continued Consent- I understand that my practitioner services generally consist of a series of treatments to achieve Maximum benefits, and this consent shall apply to all services rendered to me by my practitioner, including ongoing or intermittent treatments.