1. Purpose of Treatment I hereby authorize the medical professionals at Aesthetic Luxe Spa to perform medical aesthetic and wellness procedures. I understand that these services may include, but are not limited to: Medical weight loss programs (including Semaglutide therapy) IV hydration and vitamin therapy Pain management treatments Hormone and fertility support services Preventative wellness and recovery care Therapeutic Botox treatments Filler dissolve services
2. Risks and Clinical Expectations I understand that while these procedures are medically supervised, results vary by individual and no guarantees can be made. Common Side Effects: I acknowledge that common side effects include temporary redness, swelling, bruising, tenderness, or mild discomfort at the treatment site. Filler Dissolve Services: If receiving a filler dissolve treatment, I understand it only works on hyaluronic acid-based fillers. Multiple sessions may be required, and filler may dissolve unevenly. I agree to wait 2–4 weeks before any corrective re-filling. Medical Wellness Programs: I understand that compliance with the prescribed protocol, dietary recommendations, and follow-ups is vital to achieving results and minimizing risks.
3. Patient Health History Representation I confirm that I have disclosed a complete and accurate medical history, including current medications, allergies, pregnancies, or underlying health conditions. I will immediately notify the staff if my medical history changes before any future treatments.
4. Financial & Cancellation Policies By signing below, I acknowledge that I have read and agree to the following business policies: Cancellation/Rescheduling: A minimum of 24 hours' notice is required to cancel or reschedule. Cancellations made less than 24 hours before the scheduled appointment will incur a $50 late cancellation fee. No-Shows: Failure to arrive or cancel within the required timeframe will result in a charge of 100% of the scheduled service cost. Repeated issues may require prepayment in full for future appointments. Late Arrivals: I will aim to arrive 10–15 minutes early. If I am more than 15 minutes late, my appointment may be shortened or rescheduled, and a late cancellation fee may apply. Deposits: Certain services require a non-refundable deposit at booking, which applies toward the service cost. Deposits are only transferable if rescheduled with at least 24 hours' notice; otherwise, they are forfeited. Memberships & Packages: Membership and package appointments are subject to the same 24-hour cancellation policy. Missed or late-canceled appointments result in the loss of that service for the applicable month or package. Refunds: I understand that all sales are final. No refunds are provided once a product has been opened or administered.
5. Voluntary Consent I acknowledge that I have read this form entirely, understand the risks and benefits of the proposed treatment(s), and have had all of my questions answered to my satisfaction. I voluntarily consent to undergo treatment at Aesthetic Luxe Spa. For online booking policies, updates, and more information, I can visit www.aestheticluxspa.com. Patient Signature:
