Others

Are there any other areas of concern?

MEDICAL HISTORY

Cold sores/HSV Acne/rosacea Alopecia/hair loss Atopic dermatitis Autoimmune disorder Bleeding disorders Cancer Depression/Anxiety Diabetes Eczema/psoriasis GI disorders H/O chicken pox/shingles Heart disease Hernias Hepatitis C HIV/MRSA/Tb//G+ High blood pressure Hypo/hyperthyroidism Liver/kidney disease Lung disease (COPD/Asthma) Melasma/Pregnancy mask Metal implants/Stent/Pacemaker/Defibulator Migraines NM/motor neuron disorders/stroke Bells Palsey/Guillain Barre Scars (keloid/surgical/traumatic) Seizure/Vertigo Skin cancer Skin moles/lesions Sleep apnea/CPAP Menses Pregnant or trying Lactating Other

Others

SURGICAL HISTORY

Tummy Tuck Eyelid surgery Breast aug/reduction/lift Deep laser resurfacing Dental implants Face lift (upper/lower/nec) Facial implants: Location Hernia repair Joint replacement Liposuction Rhinoplasty Other

Others

PAST AESTHETIC PROCEDURES

Chemical Peels Skin tightening Microblading/Perm Makeup Fat reduction Dermal filler Botox Kybella Laser Treatments PDO threads Sculptra Other

Others

Medications/Supplements/Vitamins - Please List All

PHOTO CONSENT & NOTICE OF PRIVACY PRACTICES PHOTO CONSENT

I consent for medical photographs to be taken of me by staff at Novabelle MedSpa LLC. I understand that the information may be used in my medical record, for purposes of medical teaching, or for publication in medical textbooks or journals. By consenting to these medical photographs I understand that I will not receive payment from any party. Although these photographs will be used without identifying information such as my name, I understand that it is possible that someone may recognize me. Refusal to consent to photographs will in no way affect the medical care I will receive. If I wish to withdraw my consent in the future, I may do so with a written request.

Yes No

For demonstration purpose including an office photo album

Yes No

On our website and social media for prospective patients

Yes No

In print advertisements and/or professional journals

Yes No

CONSENT

I confirm that this consent form has been explained to me in terms which I understand.

NOTICE OF PRIVACY PRACTICES

I acknowledge and agree that my protected health information must be protected according to Novabelle MedSpa LLC Notice of Privacy Practices and that I have the rights to access and control such information. I acknowledge and agree that I have had all my questions regarding the use or disclosure of my protected health information and my associated rights answered to my satisfaction. While patient anonymity is preserved, there may be incidental identification through the imagery, which I accept. This consent is granted for medical education, research, or public welfare purposes, and I/we waive any rights to the imagery, releasing Novabelle MedSpa LLC and its personnel from any related claims or liabilities.


Signature for Photo Consent
(By typing your name below, you are providing your electronic signature, acknowledging that you understand and agree to the terms of this consent.)

Date

CANCELLATION & RETURN POLICY

CANCELLATION POLICY

Your appointments are very important to the team members of NOVABELLE MED SPA and these times are reserved especially for you. We understand that sometimes schedule adjustments are necessary; therefore, we respectfully request at least 24 hour notice for cancellations.
STRICT AND ENFORCED 24 HOUR CANCELLATION POLICY
Please understand that when you forget or cancel your appointment without giving enough notice, we miss the opportunity to fill that appointment time and patients on our waiting list miss the opportunity to receive services. Our appointments are confirmed 48 hours in advance because we know how easy it is to forget an appointment you booked months ago. Since the services are reserved for you personally, a Cancellation Fee will apply.

1. Less than 24 hour notice will result in a charge equal to 50% of the reserved service amount.

2. “NO SHOWS” will be charged 100% of the reserved service amount. If you prepaid for a service or package, that service will be taken out of your package as if it were used at that particular time.

3. Appointments made within the 24 hour period and need to cancel, the patient must cancel within 4 hours of appointment time or will result in a charge equal to 50% of the reserved service amount.

4. Please understand late arrivals will not receive an extension of scheduled services in order to prevent inconvenience to the next patient scheduled and the same treatment price will apply.

5. Any service requiring a 2 hour or more appointment time, will require a 50% deposit to hold that particular appointment.

Our Cancellation Policy allows us the time to inform our standby patients of any availability, as well as keeping our NOVABELLE MED SPA team member’s schedules full, thus better serving everyone. NOVABELLE MED SPA policies are presented and provided in the best quality and tradition of excellent service for our established and future patients. Thank you for viewing and supporting our policies criteria.

RETURN POLICY
* Absolutely NO refunds on services, packages or products.

* All pre-paid services and packages must be used within one year from the date of purchase.

* Product returns or exchanges must be within 30 days from date of purchase and must be unopened with your receipt. A credit will be issued to be used within NOVABELLE MED SPA Signature for cancellation and return policy
*(By typing your name bellow, you are providing your electronic signature, acknowledging that you understand and agree to the terms of this consent)*

Date

TREATMENT LIABILITY WAIVER

By signing below, you agree to the following you consent to and authorize Novabelle MedSpa LLC staff and the technician to perform a specified procedure after being informed about its nature, purpose, risks, and potential complications. You acknowledge that while the technician has explained possible benefits, there are no guarantees regarding results, which may vary based on factors like age and skin condition. You understand that additional treatments may be necessary for optimal results at an extra cost.

You confirm that you have read and understood the post-treatment care instructions and recognize the importance of following them. You will contact Novabelle MedSpa with any further questions or concerns about your treatment or home care products.

You affirm that you have provided an accurate medical history, including all known allergies and medications. You confirm that you understand this agreement, your questions have been answered, and you consent to the terms, agreeing not to hold Novabelle MedSpa or the technician liable for any undisclosed medical conditions that may affect your treatment.

I confirm that I am at least 18 years old and by signing this Consent Form, I accept the terms of this agreement and waive all responsibility towards my Technician and NOVABELLE MED SPA for any injury or damage or side effects incurred by the procedure or due to any misrepresentation of my medical history.

By typing your name below, you are providing your electronic signature, acknowledging that you understand and agree to the terms of this consent

Date

Submit