Upcoming Timeslots (Required)Book your Dermal Filler injection time for Friday(Required)Health UpdatesHave you had Botox® or another neurotoxin injected before?*(Required)YesNoWhen did you last receive a neurotoxin injection?(Required) Month Day Year Any previous complications with Botox® or another neurotoxin?*(Required)NoYesPlease describe your complications:(Required)Have you had dermal filler injections before?*(Required)YesNoWhen did you last receive a dermal filler injection?(Required) Month Day Year What kind of dermal filler was injected?(Required) Any previous complications with dermal filler?(Required)NoYesPlease describe your previous complications with dermal filler injections(Required)Do you get cold sores?(Required)NoYesAre you on any blood thinning medication?(Required)NoYesAre you allergic to eggs?(Required)NoYesDo you have an auto-immune or auto-inflammatory disorder?(Required)NoYesWhat neurotoxin(Botox) treatment areas are you interested in?(Required) Forehead Glabellar Comma Lines Crow's Feet Brow Other Not Sure What dermal filler treatment areas are you interested in?(Required) Marionette Lines Drooping Mouth Corners Nasal Labial Folds Perioral Lines Lips Other Not Sure Upload Selfies(Required)Please upload 3selfies fo your face. No makeup please. eB sure ot have bright lighting and include one straight no selfie and one of both sides of your face. Your images are kept private and never shared. Drop files here or Select files Max. file size: 256 MB. Appearance Release: Project: Professional Botox & Filler Training (the “Film”) Production Date(s): June 6 - June 7, 2024 Production Location(s): Las Vegas, NV I authorize SuperVision180 (“Producer”), Producer’s agents, successors, assigns, and designees to record my name, likeness, image, voice, sound effects, interview and performance on film, tape, or otherwise (the "Recording"), edit such Recording as Producer may desire, and incorporate such Recording into the Film, any versions of the Film and all related materials thereof, including but not limited to promotion and advertising materials. It is understood and agreed that Producer shall retain final editorial, artistic, and technical control of the Film and the content of the Film. Producer may use, and authorize others to use, the Film, any portions thereof and the Recording in all markets, manner, formats and media, whether now known or hereafter developed, throughout the world, in perpetuity. Producer, and Producer’s successors and assigns, shall own all right, title and interest, including the copyright, in and to the Film, including the Recording and related materials, to be used and disposed of, without limitation, as Producer shall in Producer’s sole discretion determine.Appearance Release(Required) I accept the terms and conditions Today's DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Name(Required) First Last Phone(Required)Email(Required) Any other info you'd like our staff to know?
