Botox & Dermal Filler Waiver
Liability Release, Assumption of Risk & Informed Consent
This agreement ("Agreement") is entered into between [Business Name], located at [Street Address], [City], [ST] ("Provider"), and the undersigned client ("Client") in connection with botox & dermal filler waiver services. By signing below, the Client acknowledges that they have read and understood each provision herein.
1. Acknowledged Risks Specific to This Procedure
The Client understands that the following risks are inherent to this specific service and cannot be eliminated even with proper technique and care:
- Bruising, swelling, asymmetry, and headache
- Rare risk of vascular occlusion or allergic reaction
- Results are temporary and not guaranteed to be symmetric
- Contraindicated during pregnancy or breastfeeding
- Strict post-treatment activity restrictions apply
2. Informed Consent to Injectable Treatment
The Client consents to the injection of neuromodulators and/or dermal fillers by a qualified provider. The Client understands that results are not permanent, that symmetry and exact outcome cannot be guaranteed, and that touch-up treatments may be recommended.
3. Specific Risks of Injectables
The Client acknowledges the risks of bruising, swelling, asymmetry, headache, drooping, lumps, and, rarely, vascular occlusion or allergic reaction. The Client confirms they are not pregnant or breastfeeding and have disclosed any neuromuscular disorders or prior reactions to these products.
4. Assumption of Risk
The Client voluntarily elects to receive the services described in this Agreement with full knowledge of the inherent risks involved. The Client understands that no procedure is entirely without risk and that individual results, reactions, and tolerances vary. The Client knowingly and freely assumes all such risks, both known and unknown, even if arising from the negligence of the Provider, and assumes full responsibility for participation.
5. Release and Waiver of Liability
In consideration of being permitted to receive the services, the Client hereby releases, waives, discharges, and covenants not to sue the Provider, its owners, employees, and agents from any and all liability, claims, demands, or causes of action arising out of or related to any loss, damage, or injury that may be sustained while receiving the services, to the fullest extent permitted by law.
6. Medical History and Disclosure
The Client affirms that they have disclosed to the Provider all relevant medical conditions, allergies, medications, and prior adverse reactions. The Client understands that withholding such information may result in injury for which the Provider bears no responsibility, and agrees to promptly notify the Provider of any change to their health status prior to receiving services.
7. Injectable Aftercare Obligations
The Client agrees to remain upright, avoid strenuous exercise, alcohol, and manipulation of the treated area for the period specified by the Provider, and to report any severe pain, vision change, or skin discoloration immediately.
8. Indemnification and Hold Harmless
The Client agrees to indemnify, defend, and hold harmless the Provider from any loss, liability, damage, or cost, including reasonable attorneys' fees, that the Provider may incur as the result of the Client's receipt of services, whether caused by the negligence of the Client or otherwise.
9. Governing Law and Venue
This Agreement shall be governed by and construed in accordance with the laws of the state in which the Provider operates, without regard to its conflict-of-law principles. Any dispute arising under this Agreement shall be brought exclusively in the state or federal courts located in that state.
10. Photography and Media Release
The Client grants the Provider permission to capture before-and-after photographs for the purposes of clinical records and, where separately initialed, marketing. The Client may withdraw marketing consent at any time in writing without affecting the validity of this Agreement.
11. Data Privacy and Communications
The Client consents to the Provider collecting and storing the personal information provided herein for the purposes of service delivery, scheduling, and follow-up care. Information will not be sold to third parties. The Client may request access to or deletion of their records consistent with applicable law.
12. Severability and Entire Agreement
If any provision of this Agreement is held to be invalid or unenforceable, the remaining provisions shall continue in full force and effect. This document constitutes the entire agreement between the parties regarding its subject matter and supersedes all prior understandings, whether written or oral.
The Client affirms they are at least 18 years of age (or the parent/legal guardian of a minor participant), have had the opportunity to ask questions, and sign this release freely.
Client signature, printed name and date, and (for a minor) the parent or guardian's signature.