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.


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

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RETURN AND REFUND POLICY

At NOVABELLE MED SPA, we want to inform you about our return and refund policy to ensure a clear and satisfactory experience:

- No Refunds: All services, packages, and products purchased are final. No refunds will be issued under any circumstances.

Use of Services and Packages: Prepaid services and packages must be used in their entirety within one (1) year from the date of purchase. After this period, any unused services will be considered expired.

Non-Transferable Treatments: All treatments purchased are personal and cannot be transferred to other individuals. This ensures that each patient receives appropriate care and treatment tailored to their individual needs.

Product Returns: Product returns are allowed only if made within thirty (30) days of purchase. Products must be unopened and in their original packaging, accompanied by the receipt.

- Acceptance of Terms: By purchasing any service or product, you fully accept the terms of this policy. Signing the consent form is a binding agreement between you and NOVABELLE MED SPA.

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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

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