Cosmetic Injection Information And Consent

For this injection of Botox Cosmetic, Radiesse, Juvederm Ultra, Juvederm Ultra Plus and/or Juvederm XC and all future injections of these or similar products, I understand and consent that:

•	The facility staff will use the highest possible level of care and skill in doing my injections.
•	Everyone’s body reacts to injectables differently, and the effects may not be what I expect or the same as with previous injections of the same product or muscle.
•	No guarantees are made about the results of the injections or the longevity of results.
•	Refunds are not available under any circumstances.
•	Touchups are available, but there will be an additional charge per syringe or unit. Touchups of Botox are $13 per unit. Other product pricing varies.