I have advised Lenox Laser & Esthetics of all allergies, particularly allergies to bacterial proteins. If I have an allergy to bacterial proteins I understand I may not be a candidate for this treatment. I have also advised Lenox Laser & Esthetics about my complete list of medications. Certain medications may alter the results and may pose a risk of tissue loss or permanent damage.

I have read and understand the pre and post treatment instructions. I agree to follow these instructions carefully. I understand that compliance with recommended pre and post procedure guidelines are crucial for healing, prevention of side effects, and complications as listed above.

I have advised Lenox Laser & Esthetics if I am pregnant, trying to get pregnant or if I am nursing.

I understand and agree that all services rendered to me are charged to me directly and that I am personally responsible for payment. The nature and purpose of the treatment have been explained to me. I have read and understand this agreement. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment.

Dermal filling agents include:

I authorize the taking of clinical photographs for my medical record, to be used for scientific purposes both in publication and presentations. I understand my identity will be protected.

I release Lenox Laser and Esthetics medical staff from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.