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Background authorization form... CONFIDENTIAL Background Check Authorization Print Name: (First) (Middle) (Last) Former Name(s) and Dates Used: Current Address Since: (Mo/Yr) (Street) (City) (Zip/State) (Mo/Yr) (Street) (City) (Zip/State)

Alligiant airline physician fo... Physician Consent Form for an Individual Who Needs to Use a Portable Oxygen Concentrator (POC) During an Allegiant Air Flight (Must be completed in full by the Customer s Physician and printed on

Fibgerpoint consent form illin... Uniform Conviction Information Act (UCIA) Fingerprint Consent Form Medical Cannabis Registry Identification Card State of Illinois Illinois Department of Public Health Pursuant to the Compassionate

Latisse consent form LATISSE INFORMED CONSENT I, , understand that I will be given a prescription for Latisse (bimatoprost ophthalmic solution) which is indicated to treat hypotrichosis (inadequate or not enough eyelashes)

Occupieramp39s consent form kn... Occupier s Consent Form The Lender The Property (address) The Applicant(s) The Advance Full name in capitals 1 2 Money Partners Limited The Advance or Further Advance which the lender proposes to

Consent form ultherapy Patient Consent Form AN ULTHERAPY TREATMENT SHOULD ONLY BE PERFORMED AFTER A COMPLETE DISCUSSION OF THE RISKS RELATED TO THE TREATMENT AND WRITTEN INFORMED CONSENT OBTAINED. PATIENT CONSENT The following points of information have been specifically discussed and I have had the opportunity to ask any questions concerning this information x The Ulthera System delivers a low amount of focused ultrasound energy to the skin. The heat from the ultrasound stimulates new collagen to form. I understand that there can be discomfort during the treatment when the ultrasound energy is delivered. I have discussed with my practitioner the options available to me to optimize my comfort during the procedure. Initial Immediately following Ultherapy the skin may appear red for a few hours. It is not uncommon to experience slight swelling for a few days following the procedure or tingling/tenderness to the touch for days to weeks following the procedure but these are mild and temporary in nature. PATIENT CONSENT The following points of information have been specifically discussed and I have had the opportunity to ask any questions concerning this information x The Ulthera System delivers a low amount of focused ultrasound energy to the skin* The heat from the ultrasound stimulates new collagen to form* I understand that there can be discomfort during the treatment when the ultrasound energy is delivered* I have discussed with my practitioner the options available to me to optimize my comfort during the procedure. Initial Immediately following Ultherapy the skin may appear red for a few hours. It is not uncommon to experience slight swelling for a few days following the procedure or tingling/tenderness to the touch for days to weeks following the procedure but these are mild and temporary in nature. Occasional temporary effects may include bruising or welts which resolve in hours to days or numbness in a select area which resolves in days to weeks. As with any medical procedure there are possible risks associated with the treatment. There is a remote risk of a burn that may or may not lead to scarring either of which will respond to medical care or temporary nerve inflammation which will resolve in a matter of days to weeks. Temporary local muscle weakness may result after treatment due to inflammation of a motor nerve. Temporary numbness may result after treatment due to inflammation of a sensory nerve. It has been explained to me that the results vary from patient to patient and occasionally the collagen building on the inside that helps counter the effects of gravity does not have a visible effect on the outside. I understand that results will unfold over the course of 3 to 6 months and that some patients may benefit from more than one treatment. I also understand that a non-invasive Ultherapy treatment is not intended to produce the same results as an invasive surgical procedure. I now authorize to begin my Ultherapy treatment. Patient Address Telephone ULTHERA EMPLOYEE STATEMENT I have fully explained to the patient the nature and purpose of the Ultherapy treatment and the potential risks associated with that treatment.

Information collection consent... Information Collection Consent Form WHAT YOUR PERSONAL INFORMATION IS Personal information is any information or an opinion (whether true or not) about you. It may range from the very sensitive (e.g.

Vac consent forms canada CONSENT FORM AND TERMS OF USE FOR RESIDENTS FOR SERVICES OF THE CANADA VISA APPLICATION CENTRE (CVAC) by VFS Global Services operated by International Organization for Migration (IOM) in Rome, Italy 1.

Botox consent form BOTOX CONSENT FORM Touch of Class Medspa Laser Center 818 502-3636 Fax 818 245-8436 Botox therapy for wrinkles is an injection treatment designed to reduce facial expression lines. They are both approved by the FDA for the treatment of wrinkles in the glabellar area* When this therapy is performed small amounts of toxin are injected into the facial muscles responsible for movement associated with lines and wrinkles. This injection weakens or paralyzes the muscle thus reducing the associated lines and wrinkles. The most common areas for this therapy are the lines between the eyes forehead wrinkles crow s feet and on occasion around the mouth. This therapy is temporary meaning it has to be repeated on a regular basis to remain effective. The weakening effect gradually begins anywhere from 24 hours to 3 days and is sometimes not complete for two weeks. During this period you may notice asymmetry or unevenness within treated areas. This asymmetry will usually correct itself as the toxin takes effect. For maximal results it is recommended that you maintain an upright posture for at least 4 hours. During this time it is also recommended that the treated area not be rubbed vigorously or massaged* You may wish to actively move by expression the treated areas during this time as this may help to increase the response of the targeted muscles. There are no known permanent side effects. There are however several possible side effects that are temporary which include Bruising Occurs at or near the injection site. This effect clears within 7-10 days. No treatment is necessary. Headache Related to the actual injections is usually mild and transient lasting less than 24 hours. May be relieved with Tylenol* Asymmetry As described above if present will be noticed in the first two weeks of therapy. May be corrected with touch-up injections if necessary. There is a fee for touch-up injections. Numbness A change in sensation noticed by some patients in the treated areas better described as dullness it is usually only noticed for a few days after treatment. Eyebrow or eyelid ptosis drooping or diplopia double vision Seen 1-2 of patients receiving this therapy is temporary lasting weeks and usually mild. Also for reasons not fully understood some patients may be less sensitive or resistant to the effects of the toxins. Very deep creases may not be completely resolved with treatment. If you are pregnant or nursing these are not recommended* I authorize photographs to be taken which may be used for medical publications lay publications education or during lectures. I understand that I will not be entitled to any payment as a result of any of these images. Because this therapy for wrinkles is considered a cosmetic procedure insurance does not pay for treatment. Payment at the time of service is requested for all patients. By signing below I agree that I have read and understand the above information and that my questions have been fully answered to my satisfaction* I understand that the practice of medicine and surgery is not an exact science and that results are not guaranteed* I agree to be personally and fully responsible for all fees.

Medication addendum to parent... North East Independent School District 10333 Broadway SAN ANTONIO, TEXAS 78217 Phone (210) 356-9244, Fax (210) 657-8677 CONFIDENTIAL Department o Department of Health Services Travel Consent/Health

Massage therapy minor consent... Minor Consent Form Minors are permitted to receive massage in the clinic. Parent or legal guardian must be present in helping complete the Health History Form for the minor along with consent for the massage therapy session. Guidelines Minors all clients under the age of 18 unless otherwise emancipated can only receive massage with written parental/legal guardian consent. In collaboration with the consenting adult and child the massage therapist will assist in establishing goals for the session s. For clients age 15 and under the parent/guardian must always be present in the treatment room* comfortable with the child being in the session room by themselves please initial here. Otherwise parent/guardian should be in the treatment room during each session* Once a comfortable therapeutic relationship has been established and the massage therapist child and parent are in the room* Appropriate draping will be used at all times during the massage only areas being massaged are uncovered* I am the parent/legal guardian of give permission for my child age to receive massage therapy from Staci Williams. In collaboration with the consenting adult and child the massage therapist will assist in establishing goals for the session s. For clients age 15 and under the parent/guardian must always be present in the treatment room* comfortable with the child being in the session room by themselves please initial here. For clients age 15 and under the parent/guardian must always be present in the treatment room* comfortable with the child being in the session room by themselves please initial here. Otherwise parent/guardian should be in the treatment room during each session* Once a comfortable therapeutic relationship has been established and the massage therapist child and parent are in the room* Appropriate draping will be used at all times during the massage only areas being massaged are uncovered* I am the parent/legal guardian of give permission for my child age to receive massage therapy from Staci Williams. In collaboration with the consenting adult and child the massage therapist will assist in establishing goals for the session s. For clients age 15 and under the parent/guardian must always be present in the treatment room* comfortable with the child being in the session room by themselves please initial here. Otherwise parent/guardian should be in the treatment room during each session* Once a comfortable therapeutic relationship has been established and the massage therapist child and parent are in the room* Appropriate draping will be used at all times during the massage only areas being massaged are uncovered* I am the parent/legal guardian of give permission for my child age to receive massage therapy from Staci Williams.

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