Medical Paperwork | SuperVision180 Models

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Model Forms 1 of 4

Please sign the following consent form

Hyaluronic Acid Dermal Filler Training Course Consent Form

To the model: You have the right to be informed about your skin condition and treatment so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you. It is simply an effort to better inform you so that you may give or withhold your consent from this treatment program.

Hyaluronic Acid Dermal Filler injectable gel is a colorless, hyaluronic acid gel that is injected into facial tissue to smooth wrinkles and folds, especially around the nose and mouth. Hyaluronic acid is a natural occurring sugar found in the human body. The role of hyaluronic acid in the skin is to deliver nutrients, hydrate the skin by holding in water, and to act as a cushioning agent.

Hyaluronic Acid Dermal Filler injectable gel is injected into areas of facial tissue where moderate to severe facial wrinkles and folds occur. Hyaluronic Acid Dermal Filler injectable gel temporarily adds volume to the skin and may give the appearance of a smoother surface. Most patients will need one treatment to achieve optimal wrinkle smoothing, and the results last about six months to one year. (The time varies according to each individual patient).

The instructor and/or student have informed me and I understand that depending on the area treated, the effect of a treatment can last an average of 12 months, but that in some cases, duration of the effects can be shorter or longer. Touch-up and follow-up treatments may be needed to sustain the desired degree of correction.

The indication for Hyaluronic Acid Dermal Filler has been explained to be by the instructor and/or student and I have had the opportunity to have all my questions answered to my satisfaction. The instructor and/or student have provided me with this consent, and I have been given time and opportunity to review it. Some of the possible risks involved with the use of the products have been explained to me and my questions concerning these risks have been answered. Some of the possibilities include the following:

After the injection(s) some common injection related reactions might occur such as swelling, redness, pain, firmness, itching, discoloration, bruising, lumps, bumps and or tenderness at the injection site. These typically resolve spontaneously within 1 — 3 days after injection into the skin.
Injection(s) may cause some discomfort during and after the procedure. Hyaluronic Acid Dermal Filler injectable gel is injected directly into the skin using a fine needle to reduce injection discomfort. The student and/or instructor may choose to numb (anesthetize) the treatment area to further minimize discomfort.
As with all skin injection procedures, there is risk of infection.

Hyaluronic Acid Dermal Filler should not be used in patients who have:

Severe allergies marked by a history of anaphylaxis or history or presence of multiple severe allergies.
Patients with a history of allergies to gram-positive bacterial proteins.

The following are important treatment considerations that should be discussed with the instructor and/or instructor in order to help avoid unsatisfactory results and complications:

Patients who are using substances that can prolong bleeding, such as aspirin or ibuprofen, as with any injection, may increase bruising or bleeding at injection site.
If laser treatment, chemical peel, or any other procedure based on active dermal response is considered after treatment with Hyaluronic Acid Dermal Filler, there is a possible risk of inflammatory reaction at the treatment site.
Hyaluronic Acid Dermal Filler should be used in caution with patients immunosuppressive therapy, or therapy used to decrease the body’s immune response, as there may be an increased risk of infection.
The safety of Hyaluronic Acid Dermal Filler injectable gel for use during pregnancy, in breast feeding, female or in patients under the age of 18 years of age has not been established.
The safety of Hyaluronic Acid Dermal Filler injectable gel in patients with a history of excessive scarring (e.g. hypertrophic scarring and keloid formations) and pigmentation disorders has not been studied.
Dental procedures performed within 2 weeks of treatment. Routine teeth cleaning is not a concern, however, periodontal dip cleaning should be discussed prior to treatment.

The safety and effectiveness of Hyaluronic Acid Dermal Filler injectable gel for the treatment of areas other than facial wrinkles and folds have not been established in controlled clinical studies. Some dermal filler companies are FDA approved for use in multiple areas, while others are not. Should you have a concern whether the filler being used is FDA approved in the area of treatment, please discuss this with your instructor.

I have been told what I can expect from the proposed procedure, but that no results can be guaranteed or assumed, and no such guarantees or assurances have been given to me. Usage of less than the recommended quantity of filler may result in less than desired effect. Enhancement with additional filler may be necessary two weeks later.

By signing this consent, I agree to be treated by a student with Hyaluronic Acid Dermal Filler as described above. I acknowledge and understand the procedure and the risks, and they have been explained to my satisfaction. I agree to hold SuperVision, Inc., Natausha Spears and the student injecting me, harmless of the described risks, on the condition that the injections of the Products are administered in accordance with appropriate guidelines.

I understand that funds paid toward the purchase of Hyaluronic Acid Dermal Filler are non-refundable.

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I understand that by signing above I have read and acknowledged the information and give my consent.

Model Forms 2 of 4

Please sign the following consent form

Neurotoxin Cosmetic Botulinum Toxin Type A Training Course Consent Form

To the patient: You have the right to be informed about your skin condition and treatment so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you. It is simply an effort to better inform you so that you may give or withhold your consent from this treatment program.

I have requested this attempt to improve my facial expression lines with Neurotoxins, another name for botulinum toxin. These injections have been used for more than a decade in children and adults to improve the problem of muscle spasm of the facial muscles. This toxin has also been useful to correct double vision due to muscle imbalance. Injects of minute amounts weaken the muscle and prevent frowning, crow's feet and expression lines. Although the results are usually dramatic, I have been informed that the practice of medicine is not an exact science and that no guarantees can or have been made concerning expected results in my case.

Initial if true(Required)

The solution is injected with a small needle into the muscle. You see the benefits develop over the next 5 - 7 days, with full benefits at 14 days. Less frowning will be possible.

Initial if true(Required)

Side effects and complications are usually minimal. Occasionally, slight swelling and/or bruising may last for several days after the injection. I have been advised of the risks involved in such treatment, the expected benefits of such treatment, and alternative treatment, including no treatment at all.

Initial if true(Required)

I understand that the most significant risk could be a drooping brow or eyelid, or weakness in the muscle that closes the eye as well as facial asymmetry or smile asymmetry, if adjacent muscles are affected by the injection. This will usually resolve after several weeks.

Initial if true(Required)

I understand that the injection of neurotoxin is temporary, but that after multiple injections there may be permanent effects.

Initial if true(Required)

I understand the contraindications to this treatment include pregnancy, bleeding disorders, neuromuscular disorders, and allergies to albumin (egg) products. I understand the contraindications and I possess none of these conditions.

Initial if true(Required)

I have received a copy of the MEDICATION GUIDE for neurotoxins and neurotoxins cosmetic for Injection. Download Medication Guide BOTOX®

Initial if true(Required)

I understand that funds paid for neurotoxins are non-refundable.

Initial if true(Required)

By signing this consent, I agree to be treated by a student with Neurotoxins as described above. I acknowledge and understand the procedure and the risks, and they have been explained to my satisfaction. I agree to hold the practitioner harmless of the described risks, on the condition that the injections of the Products are administered in accordance with appropriate guidelines.

Model's Signature(Required)

Model's full legal name(Required)

Form consent(Required)

By signing this consent, I agree to be treated by a student with Neurotoxins as described above. I acknowledge and understand the procedure and the risks, and they have been explained to my satisfaction. I agree to hold the practitioner harmless of the described risks, on the condition that the injections of the Products are administered in accordance with appropriate guidelines.

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Model Paperwork

Model Forms 1 of 4

Hyaluronic Acid Dermal Filler Training Course Consent Form

Model Forms 2 of 4

Neurotoxin Cosmetic Botulinum Toxin Type A Training Course Consent Form

Model Forms 3 of 4

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