FAQ’s

GENERAL CONSENT
TREATMENT, PROCEDURES, PHOTOGRAPHY, VIDEO RECORDING, AND PROVIDER TO
CLIENT TREATMENT .
You have been given information about your condition and the recommended procedure(s) to
be used. This consent form is designed to provide a electronic and written confirmation of such
discussions by recording some of the more significant medical information given to you. It is
intended to make you better informed so that you may give or withhold your consent to the
proposed procedure(s).
Heather Merlo, APRN, FNP-C, has explained to me that the condition(s) in my case discussed
during our initial consultation, and any consultation thereafter, would benefit from treatments
offered at Sei Tu Bella Aesthetics and offered a treatment modality and ‘or intervention. I have
been provided ample time to ask any questions regarding to the procedure and thereafter.
Risks/Benefits of Proposed Procedure(s):
Just as there may be benefits to the procedure(s) proposed, I also understand that interventions
and medical procedures involve risks. These risks include the following but not limited to allergic
reaction, bleeding, blood clots, infections, paralysis, vascular compromise and or occlusion,
burns, discolorations, granulomas, adverse side effects of drugs, blindness, and in the most rare
and unfortunate event of even loss of bodily function or life.
I understand that the medical clinic is recorded for safety and security purposes and can be
used for any means to protect all provider and Sei Tu Bella Aesthetics LLC
I understand that I have been instructed to activate my treatment portal and there I can find my
client paperwork, consents, and pre and post instructions as well via the website. I understand
that at any time I am unsure of the treatment process, pre and post treatment instructions, risk,
benefits, or any other concern that I have been provider a means to reach the clinic for
additional guidance.
I understand that if I do not disclose all of my medical history and physical which includes
previous and current treatment interventions , including any changes after I sign this consent,
that it can lead to a adverse effect or event.
I also realize that there are particular risks associated with the procedure(s) proposed for me
and that these risks include, but are not limited to, those enumerated in the addendum.
Complications; Unforeseen Conditions; Results: I am aware that in the practice of medicine,
other unexpected risks or complications not discussed may occur. I also understand that during
the course of the proposed procedure(s) unforeseen conditions may be revealed requiring the
performance of additional procedures, and I authorize such procedures to be performed. I
further acknowledge that no guarantees or promises have been made to me concerning the
results of any procedure or treatment.
Acknowledgments: The available alternatives, the potential benefits and risks of the proposed
procedure(s), and the likely result without such treatment, have been explained to me. I
understand what has been discussed with me as well as the contents of this consent form, and
have been given the opportunity to ask questions and have received satisfactory answers. I
have been made aware of all consents and pre and post treatment instructions to optimize the
procedure are made available to me via the website and the portal.
Consent to Procedure(s) and Treatment: Having read this form and talked with the provider, my
signature below acknowledges that: I voluntarily give my authorization and consent to the
performance of the procedures agreed upon and The following consent is general consent for
treatment as a client at Sei Tu Bella Aesthetics and includes verbal consent to any and all
procedures, treatments, interventions, preformed while remaining a client at Sei Tu Bella
Aesthetics.
I take full liability and responsibility for any and all risks, undesired outcomes, or adverse events
associated with the procedure and will not hold the providers or Sei Tu Bella Aesthetics LLC for
any unfavorable outcome or adverse event. I release Sei Tu Bella Aesthetics LLC, owners, and
medical staff from liability associated with the procedure. This consent form is freely and
voluntarily executed and shall be binding upon my spouse, relatives, legal representatives,
heirs, administrators, successors and
assigns .
I relieve Heather Merlo, APRN, FNP-C
Medical Director Dr. Fernando Jara
Sei Tu Bella Aesthetics LLC, from all legal action pertaining to this treatment.

GENERAL CONSENT
TREATMENT, PROCEDURES, PHOTOGRAPHY, VIDEO RECORDING, AND PROVIDER TO
CLIENT TREATMENT .
You have been given information about your condition and the recommended procedure(s) to
be used. This consent form is designed to provide a electronic and written confirmation of such
discussions by recording some of the more significant medical information given to you. It is
intended to make you better informed so that you may give or withhold your consent to the
proposed procedure(s).
Heather Merlo, APRN, FNP-C, has explained to me that the condition(s) in my case discussed
during our initial consultation, and any consultation thereafter, would benefit from treatments
offered at Sei Tu Bella Aesthetics and offered a treatment modality and ‘or intervention. I have
been provided ample time to ask any questions regarding to the procedure and thereafter.
Risks/Benefits of Proposed Procedure(s):
Just as there may be benefits to the procedure(s) proposed, I also understand that interventions
and medical procedures involve risks. These risks include the following but not limited to allergic
reaction, bleeding, blood clots, infections, paralysis, vascular compromise and or occlusion,
burns, discolorations, granulomas, adverse side effects of drugs, blindness, and in the most rare
and unfortunate event of even loss of bodily function or life.
I understand that the medical clinic is recorded for safety and security purposes and can be
used for any means to protect all provider and Sei Tu Bella Aesthetics LLC
I understand that I have been instructed to activate my treatment portal and there I can find my
client paperwork, consents, and pre and post instructions as well via the website. I understand
that at any time I am unsure of the treatment process, pre and post treatment instructions, risk,
benefits, or any other concern that I have been provider a means to reach the clinic for
additional guidance.
I understand that if I do not disclose all of my medical history and physical which includes
previous and current treatment interventions , including any changes after I sign this consent,
that it can lead to a adverse effect or event.
I also realize that there are particular risks associated with the procedure(s) proposed for me
and that these risks include, but are not limited to, those enumerated in the addendum.
Complications; Unforeseen Conditions; Results: I am aware that in the practice of medicine,
other unexpected risks or complications not discussed may occur. I also understand that during
the course of the proposed procedure(s) unforeseen conditions may be revealed requiring the
performance of additional procedures, and I authorize such procedures to be performed. I
further acknowledge that no guarantees or promises have been made to me concerning the
results of any procedure or treatment.
Acknowledgments: The available alternatives, the potential benefits and risks of the proposed
procedure(s), and the likely result without such treatment, have been explained to me. I
understand what has been discussed with me as well as the contents of this consent form, and
have been given the opportunity to ask questions and have received satisfactory answers. I
have been made aware of all consents and pre and post treatment instructions to optimize the
procedure are made available to me via the website and the portal.
Consent to Procedure(s) and Treatment: Having read this form and talked with the provider, my
signature below acknowledges that: I voluntarily give my authorization and consent to the
performance of the procedures agreed upon and The following consent is general consent for
treatment as a client at Sei Tu Bella Aesthetics and includes verbal consent to any and all
procedures, treatments, interventions, preformed while remaining a client at Sei Tu Bella
Aesthetics.
I take full liability and responsibility for any and all risks, undesired outcomes, or adverse events
associated with the procedure and will not hold the providers or Sei Tu Bella Aesthetics LLC for
any unfavorable outcome or adverse event. I release Sei Tu Bella Aesthetics LLC, owners, and
medical staff from liability associated with the procedure. This consent form is freely and
voluntarily executed and shall be binding upon my spouse, relatives, legal representatives,
heirs, administrators, successors and
assigns .
I relieve Heather Merlo, APRN, FNP-C
Medical Director Dr. Fernando Jara
Sei Tu Bella Aesthetics LLC, from all legal action pertaining to this treatment.

Dermaplaning Consent Form
Please initial each line next to each statement prior to treatment
_______ I understand that Dermaplaning is the process of removing superficial layers of dead
skin cells and vellus hair on the skin’s surface by the use of a sterile blade. _______ I
understand that there may be unforeseen risks with Dermaplaning such as nicking, scraping or
abrading the skin with the blade.
_______ I understand that possible side effects of the treatment area can include mild redness
of the skin, irritation and dryness.
_______ I understand that if a chemical peel is part of this treatment, that the sensation and
penetration of the peel will be enhanced. This may cause minor skin irritation, mild discomfort,
and tenderness, lightening or darkening of the skin, peeling and activation of cold sores.
_______ I understand the results of this treatment may vary due to conditions such as age,
condition of skin, sun damage, climate, etc.
_______ I understand that in order to see significant results these treatments need to be done
in a series and in combination with using active ingredient skin care products.
_______ I understand that direct sun exposure, including tanning beds, is not recommended
while undergoing treatment and the use of a daily sun block protection is mandatory.
_______ I understand that any facial injections should be avoided 10 days before this treatment.
_______ I am not using Retin A®, or other retinol derivatives, products containing Alpha
Hydroxy Acids (AHA) or Beta Hydroxy Acids (BHA) and have been off these products at least 3
days prior to treatment.
_______ I will call my practitioner if I have any questions or concerns about my treatment.
_______ I have been advised not to exercise after my treatment.
I agree to have this treatment performed on me. I further agree to follow all post-care
instructions. Prior to receiving any treatment, I have been candid in revealing any condition that
may have a bearing on this procedure. I am over 18 years of age.
I understand that the treatment may involve risks of complication or injury from both known and
unknown causes, and I freely assume those risks. Prior to
receiving treatment, I have been candid in revealing any condition that may have a bearing on
this procedure.
I consent and authorize Sei Tu Bella Aesthetics , LLC, and it’s affiliates to perform the procedure
listed on me. I certify that I have read this entire informed consent and I understand and agree
to the information provided in the form. My questions regarding the procedure have been
answered satisfactorily. I hereby release Heather Merlo, APRN, FNP-C, Medical Director Dr.
Fernando Jara, Sei Tu Bella Aesthetics LLC from all liabilities associated with this procedure.
This consent is valid for all of my treatments in the future as well.

INFORMED CONSENT– DERMAL FILLER INJECTION
This is an informed consent document which has been prepared to help inform you concerning
Hyaluronic Acid Filler such as Restylane®, Juvaderm, Versa, & Belotero. (Non-Animal Stabilized
Hyaluronic Acid) tissue filler injection therapy, its risks, and alternative treatments. As well as
Radiesse , a sterile, latex-free, non-pyrogenic, semi- solid, cohesive subdermal, injectable
implant, whose principal component is synthetic calcium hydroxylapatite, a biocompatible
material with over 20 years of use in medicine, approved for use in hands, cheeks, and pre-jowl
sulcus. Hyaluronic acid is a naturally occurring substance that is found within all mammals. It is
a material that is contained in various soft tissues. Hyaluronic acid can be synthetically
produced from a process of bacterial fermentation, chemically stabilized, and purified for use as
an injectable soft tissue filler (non-animal, stabilized hyaluronic acid). The hyaluronic acid in
Dermal-Fillers is biocompatible and is a totally non-animal product; there is little risk of animalbased disease transmission or allergic reaction. Dermal-fillers can be performed in areas
involving the face, eyebrows, temples, under eyes, nose, jaw, chin, jowls, cheeks, hands,
forehead, and lips, just to name a few and some areas are considered Off-Label use, not FDA
approved areas. Dermal-Filler injections contain local anesthetic in the syringe to diminish
discomfort. Continuing treatments are necessary in order to maintain the effect of Fillers over
time, they do not stop the aging process. Once injected, dermal-fillers will be slowly absorbed by
the body. The length of effect for fillers injections is variable and depends on the person.
ALTERNATIVE TREATMENTS
Alternative forms of management include not treating the skin wrinkles or soft tissue
depressions by any means. Improvement of skin wrinkles and soft tissue depressions may be
accomplished by other treatments: laser treatments, chemical skin-peels, other skin procedures,
or alternative types of tissue fillers.
RISKS OF FILLER INJECTIONS
An individual’s choice to undergo this procedure is based on the comparison of the risk to
potential benefit.
Normal Occurrences during Tissue Filler Injections include:
Bleeding and Swelling – Swelling (edema) is a normal occurrence following the injections. It
decreases after a few days or weeks. Erythema (Skin Redness) – Erythema in the skin occurs
after injections. It can be present for a few days after the procedure. Needle Marks – Visible
needle marks from the injections occur normally and resolve in a few days.
Acne-Like Skin Eruptions – skin eruptions can occur following the injection of tissue fillers that
generally resolve within a few days. Skin Lumpiness – Lumpiness can be treated with
hyaluronidase to smooth it out if necessary.
Visible Tissue Filler Material – This can be resolved with hyaluronidase
Asymmetry – It may not be possible to achieve or maintain exact symmetry with tissue filer
injections.
Pain – Discomfort associated with injections is normal and usually of short duration. RISKS OF
DERMAL-FILLER INJECTIONS
Damage to Deeper Structures – Deeper structures such as nerves and blood vessels may be
damaged during the course of injection. Injury to deeper structures may be temporary or
permanent.
Infection – unusual, herpes outbreaks can be triggered
Vascular compression and vascular occlusion- if this were to occur immediately or delayed ,the
appropriate protocol would be initiated for reversal. Therefore, it is imperative you follow the
post instructions template and what to look for such as pain, skin color changes ext. if you
notice or feel anything that makes you concerned you are to contact the clinic immediately or
seek emergency evaluation.
Skin Necrosis – It is very unusual to experience death of skin and deeper soft tissues after
dermal-filler injections. Skin necrosis can produce unacceptable scarring. Should this
complication occur, additional treatments, or surgery may be necessary.
Allergic Reactions and Hypersensitivity
Scarring – Dermal-fillers maybe susceptible to keloid formation or hypertrophic scarring.
Granulomas – Painful masses in the skin and deeper tissues after a dermal-filler injection are
extremely rare. Should these occur, additional treatments including surgery may be necessary.
Antibodies to Fillers – Presence of antibodies to hyaluronic acid tissue fillers may reduce the
effectiveness of this material or produce a reaction in subsequent injections. The health
significance of antibodies to hyaluronic acid tissue fillers is unknown. Accidental Intra-Arterial
Injection – It is extremely rare and unpredictable
Under /Over Correction – The amount of correction may be inadequate or excessive. It may not
be possible to control the process of injection of tissue fillers due to factors attributable to each
patient’s situation. If under correction occurs, you may be advised to consider additional
injections of tissue filler materials. If over correction occurs, the use of hyaluronidase can
decrease the volume. Migration of Dermal-Fillers – Dermal- fillers may migrate from its original
injection site and produce visible fullness in adjacent tissue or other unintended effects.
Drug and Local Anesthetic Reactions – There is the possibility that a systemic reaction could
occur from the local anesthetic when tissue filler injections are performed. This would include
the possibility of light-headedness, numbness, and, allergic reaction, and fainting. Medical
treatment of these conditions may be necessary.
Unsatisfactory Result – Dermal-filler injections alone may not produce an outcome that meets
your expectations for improvement in wrinkles or soft tissue depressions. There is the possibility
of a poor or inadequate response from filler injection(s).
Pregnancy and Nursing Mothers – Animal reproduction studies have not been performed to
determine if dermal-filler could produce fetal harm. It is not known if Restylane®, Juvaderm,
Versa, or Beloter or its breakdown products can be excreted in human milk. It is not
recommended that pregnant women or nursing mothers receive dermal-filler treatments.
Drug Interactions – It is not known if fillers reacts with other drugs within the body. Label FDA
Issues
There are many devices, medications and injectable fillers that are approved for specific use by
the FDA, but some proposed use is “Off-Label”, that is not specifically approved by the FDA. It
is important that you understand this proposed use is not experimental and your physician
believes it to be safe and effective.
FINANCIAL RESPONSIBILITIES
I understand and agree that all services rendered to me are charged to me directly and that I am
personally responsible for payment. The fees charged for this procedure do not include any
potential future costs for additional procedures that you elect to have or require in order to
revise, optimize, or complete your outcome.
Additional costs may occur should complications develop from the injections and will also be
your responsibility. In signing the consent for this procedure, you acknowledge that you have
been informed about its risk and consequences and accept responsibility for the clinical
decisions that were made along with the financial costs of all future treatments.
I understand and unconditionally and irrevocably accept this & that all costs are NONREFUNDABLE
DISCLAIMER
Informed consent documents should not be considered all-inclusive in defining other methods of
care and risks encountered.
I hereby authorize Natural Injections and it’s trained licensed designees to perform the injection
of hyaluronic acid dermal fillers such as Radiesse, RHA, Juvaderm, Resylane, Versa, or
Belotero
1. I have received and read the INFORMED CONSENT and PRE & POST PROCEDURE
INSTRUCTIONS that were explained to me & I agree to follow all instructions, to follow up as
directed, and to notify the office if any problems or questions arise.
2. I recognize that during the course of the procedure and medical treatment or anesthesia,
unforeseen conditions may necessitate different procedures than those above. I therefore
authorize the above mentioned provider to perform such other procedures that are in the
exercise of his or her professional judgment necessary and desirable.
3. I consent to the administration of such anesthetics considered necessary or advisable. I
understand that all forms of anesthesia involve risk and the possibility of complications, injury,
and sometimes death.
4. The nature and purpose of the treatment have been explained to me. I understand what my
provider can and cannot do, and I understand there are no warranties or guarantees implied or
specific about my outcome. I have had the opportunity to explain my goals and understand
which desired outcomes are realistic and which are not. I have read and understand this
agreement. All of my questions have been answered to my satisfaction and I consent to the
terms of this agreement. Alternative methods of treatment and their risks and benefits have
been explained to me.
5. I understand that I have the right to refuse treatment. By signing this form, I elect to proceed
with treatment.
6. I consent to be photographed or televised before, during, and after the procedure(s) to be
performed, including appropriate portions of my body, for medical, scientific or educational
portions of my body, for medical, scientific or educational purposes, provided my identity is not
revealed by the pictures.
7. For purposes of advancing medical education, I consent to the admittance of observers to the
treatment room.
I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED ITEMS (1-7).
I AM SATISFIED WITH THE EXPLANATION.
I take full liability and responsibility for any and all risks, undesired outcomes, or adverse events
associated with the injections and will not hold the providers liable for any unfavorable outcome
or adverse event. I release Sei Tu Bella Aesthetics LLC, owners, and medical staff from liability
associated with the procedure. This consent form is freely and voluntarily executed and shall be
binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and
assigns . I relieve Heather Merlo, APRN, FNP-C, Medical Director Dr. Fernando Jara and Sei Tu
Bella Aesthetics LLC, from all legal action pertaining to this treatment.

Informed Consent for B Vitamin and Lipotropic Injection Therapy
This document is intended to serve as confirmation of informed consent for injection therapy at
Sei Tu Bella Aesthetics
I have informed Sei Tu Bella Aesthetics of any known allergies to drugs or other substances, or
of any past reactions to injections. I have informed the providers of all my medical conditions
and current medications. I understand that I have the right to be informed of the procedure, any
feasible alternative options, and the risks and benefits. Except in emergencies, procedures are
not performed until I have had an opportunity to receive such information and to give my
informed consent.
I understand that:
1
2 3 •
• • 1 •
following, MICC, B12, LIPO-MINO-MIX, TRI-IMMUNE
I am aware that other unforeseeable complications could occur. I do not expect Sei Tu Bella
Aesthetics to anticipate and or explain all risk and possible complications. I rely on the
technician to exercise judgement during the course of treatment with regard to any procedure. I
understand the risks and benefits of the procedure and have had the opportunity to have all of
my questions answered. I understand that I have the right to consent to or refuse any proposed
treatment at any time prior to its performance. When purchasing Vitamin B or Lipotropic
Injections from Sei Tu Bella Aesthetics, you agree to the following:
• I have given my consent to injection therapy with any different or further procedures which, Sei
Tu Bella Aesthetics, may be indicated.
The procedure involves inserting a needle into various areas of the body and injecting of
vitamins and other homeopathic remedies.
Risks of injection therapies include but are not limited to:
Occasionally to commonly
Discomfort, severe pain, bruising, inflammation, injury and numbness at the site of injection.
Fatigue, dizziness, or light-head feeling after the injections.
Fainting or loss of consciousness during the procedure. Extremely rare:
Severe allergic reaction, anaphylaxis, infection.
I understand that some of the treatment injection may include of a combination of the
• I understand the information provided on this form and agree to the foregoing.
• The procedure(s) set forth above has been adequately explained to me
• I have received all the information and explanation I desire concerning the
procedure.
• I authorize and consent to the performance of the procedure(s).have been
provided a copy of Notice of Privacy Practices at Sei Tu Bella Aesthetics
I understand that the treatment may involve risks of complication or injury from both known and
unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been
candid in revealing any condition that may have a bearing on this procedure.
I consent and authorize Sei Tu Bella Aesthetics , LLC, and it’s affiliates to perform the procedure
listed on me. I certify that I have read this entire informed consent and I understand and agree
to the information provided in the form. My questions regarding the procedure have been
answered satisfactorily. I hereby release Heather Merlo, APRN, FNP-C, Medical Director Dr.
Fernando Jara, Sei Tu Bella Aesthetics LLC from all liabilities associated with this procedure.
This consent is valid for all of my
treatments in the future as well.

HOW TO PREPARE AND POST CARE AFTER YOUR MORPHEUS PROCEDURE
PRE & POST MORPHEUS8 TREATMENT INSTRUCTIONS
Pre-treatment Instructions
● Topical retinoid therapy should be discontinued 2-4 days prior to treatment
● Avoid any prolonged exposure to the sun, if you must be in the sun use a zinc oxide
sunscreen of at least SPF 30.
● Avoid taking anticoagulants (aspirin, mobic, ibuprofen, naproxen) for one week if medical
condition allows.
● Arrive to your appointment with clean skin. There should be no lotion, makeup, perfume,
powder, self tanner, bath or shower oil present on the skin to be treated. You will be given the
opportunity to remove your make-up in the event this was not possible.
What to Expect
• Immediately after your treatment most patients will experience a clinical
endpoint of erythema (redness) for 1-3 days, however for more aggressive treatments this may
last longer. Slight to moderate edema (swelling) and mild to moderate sunburn sensation are
also common post treatment and may last 1-3 days. Skin may crust and peel for 2-7 days
depending on the treatment setting.
• Skin may feel warm and tighter than usual
• Skin may crust and peel for 3-7 days after treatment
• Redness and swelling may last for 3-4 days
• On more aggressive settings and deeper penetration (4mm-8mm) the healing
time maybe longer than previously discussed.
• You may have a acne breakout after the treatment, this is normal and often
expected as the procedure can trigger a flare.

Post-treatment Instructions
• You may search the internet and read multiple different ways to care for your skin post
Morpheus. The following is what we have found in our practice to have the greatest impact and it
is what we recommend for you to achieve optimal results.
• You can wash your face in the evening and morning immediately following your procedure and
continue thereafter.
• SPF can be applied after 24 hours. We recommend our Skinbetter Science tinted SPF as it is
a flawless SPF that closely resembles a makeup.
• Make-up is to be avoided for at least 24 hours however 72 hours is optimal.
• If your Morpheus treatment came with a skincare package, you can begin using
the products at the 72 hour mark unless otherwise indicated.
• Retinoids may be used 5-7 days after treatment.
• There are no restrictions on bathing except to treat the skin gently, avoid
scrubbing or trauma to the treated areas, as if you had a sunburn.
• Avoid hot tubes, spas, lakes ext until; all redness has resolved.
• Avoid sun exposure to reduce the chance of hyperpigmentation (darker
pigmentation).
You may not notice immediate results, in fact sometimes your skin may appear to get worse
before it repairs and regenerates.This is normal and a expected outcome. You will notice results
as your skin starts to heal and repair as well as long term improvements in your skin as the
weeks pass. The time for skin cell turnover is 28 days so most people will begin to see
increased results after this time. This is also the time it takes to rebuild collagen and elastin.
Results will take time to see but will be worth the wait.You will continue to build new collagen
and elastic for up to 6 months.

Microneedling with SkinPen ® Patient Consent Form
DESCRIPTION OF THE PROCEDURE Microneedling procedures allow for controlled induction
of the skin’s self-repair mechanism by creating micro“injuries” in the skin, which triggers new
collagen synthesis. The result is smoother, younger- looking skin.
Microneedling procedures are performed in a safe and precise manner with the use of the
sterile needle head. The procedure is normally completed within 30–60 minutes, depending on
the required procedure and anatomical site.
SIDE EFFECTS After the procedure, the skin will be red and flushed in appearance, similar to a
moderate sunburn. You may also experience skin tightness and mild sensitivity to touch on
certain areas. This will diminish significantly within a few hours following the procedure. Within
the next 24-48 hours, the skin will have returned to normal. After three days, there is rarely any
evidence that the procedure has taken place.
CONTRAINDICATIONS Microneedling is contraindicated for patients with: keloid scars,
scleroderma, collagen vascular diseases or cardiac abnormalities, a hemorrhagic disorder or
hemostatic dysfunction, active bacterial or fungal infection. PRECAUTIONS AND WARNINGS
Microneedling has not been evaluated in the following patient populations, and as such,
precautions should be taken when determining whether the SkinPen procedure is adequate for
the patient: scars and stretch marks less than one year old; women who are pregnant or
nursing; keloid scars; patients with history of eczema, psoriasis and other chronic conditions;
patients with history of actinic (solar) keratosis; patients with history of herpes simplex
infections; diabetics or patients with wound- healing deficiencies; patients on
immunosuppressive therapy; and skin with presence of raised moles or warts on targeted area.
PATIENT CONSENT I understand that results will vary among individuals. I understand that
although I may see a change after my first procedure, I may require a series of sessions to
obtain my desired outcome.
The procedure and side effects have been explained to me including alternative methods, as
have the advantages and disadvantages.
I am advised that though good results are expected, the possibility and nature of complications
cannot be accurately anticipated, therefore, there can be no guarantee as expressed or implied
either as to the success or other result of the procedure. I am aware that microneedling
procedure is not permanent and natural degradation may occur over time.
I state that I have read (or it has been read to me) and I understand this consent and I
understand the information contained in it.
I have had the opportunity to ask any questions about the procedure including risks or
alternatives and acknowledge that all my questions about the procedure have been answered in
a satisfactory manner.
I take full liability and responsibility for any and all risks, undesired outcomes, or adverse events
associated with the injections and will not hold the providers or liable for any unfavorable
outcome or adverse event. I release Sei Tu Bella Aesthetics LLC, owners, and medical staff
from liability associated with the procedure. This consent form is freely and voluntarily executed
and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators,
successors and assigns . I relieve Heather Merlo, APRN, FNP-C, Medical Director Dr. Fernando
Jara and Sei Tu Bella Aesthetics LLC, from all legal action pertaining to this treatment.

I have been given the opportunity to ask questions and my questions have been answered to
my satisfaction. I also state that I read and write in English. I hereby consent to the Botulinum
Toxin Injection Treatment and hereby authorize the provider to perform the Botulinum Toxin
Injection Treatment. I understand that I will be injected with Botulinum A Toxin in the area of the
facial muscles to paralyze these muscles temporarily or in the forehead or crowâ€TMs feet
around the lateral area of the eyes. I understand my treatment may include both FDA approved
locations as well as commonly performed cosmetically treated areas based on desired effects.
Botulinum A Toxin injection has been FDA approved for use in the cosmetic treatment for
glabellar frown lines – the wrinkles between the eyebrows and crowâ€TMs feet. I understand
there are other risks for the non-FDA approved uses of Botulinum A Toxin. Injection of Botulinum
A Toxin into the small muscles between the brows causes those specific muscles to halt their
function (be paralyzed), thereby improving the appearance of the wrinkles. I understand the goal
is to decrease the wrinkles in the treated area. This paralysis is temporary, and typically lasts
three to four months although longevity varies amongst individuals. It has been explained to me
that other alternatives are available. The possible side effects of Botulinum A Toxin include but
are not limited to: Local numbness, rash, pain at the injection site, flu like symptoms, headache
Infection: Infections can occur which in most cases are easily treatable but in rare cases a
permanent scarring in the area can occur. Bruising may occur and may last several weeks Most
people have lightly swollen pinkish bumps at injection sites for a couple of hours or even several
days. Although many people with chronic headaches or migraines often get relief from
Botulinum A Toxin, a small percent of patients get headaches following treatment with Botulinum
A Toxin, most commonly on the first 1-7 days. In a very small percentage of patients these
headaches can persist for several days or weeks. Respiratory problems such as bronchitis or
sinusitis, nausea, dizziness, and tightness or irritation of the skin. While local weakness of the
injected muscles is representative of the expected
pharmacological action of Botulinum A Toxin, weakness of adjacent muscles may occur as a
result of the spread of the toxin. Treatments: I understand more than one injection may be
needed to achieve a satisfactory result. Another risk when injecting Botulinum A Toxin around
the eyes included corneal exposure because people may not be able to blink the eyelids as
often as they should to protect the eye. This inability to protect the eye has been associated with
damage to the eye as impaired vision, or double vision, which is usually temporary. This
reduced blinking has been associated with corneal ulcerations. There are medications that can
help lift the eyelid, however, if the drooping is too great the eye drops are not that effective.
These side effects can last for several weeks or longer. This occurs in 2-5 percent of patients. I
will follow all aftercare instructions as it is crucial I do so for healing. As Botulinum A Toxin
injection is not an exact science and facial anatomy and symmetry are highly variable from
patient to patient, there might be an uneven appearance of the face with some muscles more
affected by the Botulinum A Toxin than others. In most cases this uneven appearance can
sometimes be corrected by injecting Botulinum A Toxin in the same or nearby muscles. However
in some cases this uneven appearance can persist for several weeks or months until the full
effects of the product have subsided. This list is not meant to be inclusive of all possible risks
associated with Botulinum A Toxin as there are both known and unknown side effects
associated with any medication or procedure. Botulinum A Toxin should not be administered to a
pregnant or nursing woman. Additionally, the number of units injected is an estimate of the
amount of Botulinum A Toxin required to paralyze the muscles. I understand there is no
guarantee of results of any treatment. As with all injectable treatments, there is a risk of
infection, vessel occlusion, granulomas, abscess formation and hypersensitive reaction.
Approved Uses BOTOX® Cosmetic is a prescription medicine that is injected into muscles and
used to temporarily improve the look of both moderate to severe crowâ€TMs feet lines and
frown lines between the eyebrows in adults. IMPORTANT SAFETY INFORMATION BOTOX®
Cosmetic may cause serious side effects that can be life threatening. Get medical help right
away if you have any of these problems any time (hours to weeks) after injection of BOTOX®
Cosmetic: Problems swallowing, speaking, or breathing, due to weakening of associated
muscles, can be severe and result in loss of life. You are at the highest risk if these problems
are pre-existing before injection. Swallowing problems may last for several months Spread of
toxin effects. The effect of botulinum toxin may affect areas away from the injection site and
cause serious symptoms including: loss of strength and Approved Uses BOTOX® Cosmetic is
a prescription medicine that is injected into muscles and used to temporarily improve the look of
both moderate to severe crowâ€TMs feet lines and frown lines between the eyebrows in adults.
IMPORTANT SAFETY INFORMATION BOTOX® Cosmetic may cause serious side effects
that can be life threatening. Get medical help right away if you have any of these problems any
time (hours to weeks) after injection of BOTOX® Cosmetic: Problems swallowing, speaking, or
breathing, due to weakening of associated muscles, can be severe and result in loss of life. You
are at the highest risk if these problems are pre-existing before injection. Swallowing problems
may last for several months Spread of toxin effects. The effect of botulinum toxin may affect
areas away from the injection site and cause serious symptoms including: loss of strength and
all-over muscle weakness, double vision, blurred vision and drooping eyelids, hoarseness or
change or loss of voice, trouble saying words clearly, loss of bladder control, trouble breathing,
trouble swallowing BOTOX® Cosmetic dosing units are not the same as, or comparable to,
any other botulinum toxin product. There has not been a confirmed serious case of spread of
toxin effect when BOTOX® Cosmetic has been used at the recommended dose to treat frown
lines, crowâ€TMs feet lines, or both at the same time. BOTOX® Cosmetic may cause loss of
strength or general muscle weakness, vision problems, or dizziness within hours to weeks of
taking BOTOX® Cosmetic. If this happens, do not drive a car, operate machinery, or do other
dangerous activities. Serious and/or immediate allergic reactions have been reported. They
include: itching, rash, red itchy welts, wheezing, asthma symptoms, or dizziness or feeling faint.
Get medical help right away if you are wheezing or have asthma symptoms, or if you become
dizzy or faint. Do not take BOTOX® Cosmetic if you: are allergic to any of the ingredients in
BOTOX® Cosmetic (see Medication Guide for ingredients); had an allergic reaction to any
other botulinum toxin product such as Myobloc® (rimabotulinumtoxinB), Dysport®
(abobotulinumtoxinA), or Xeomin® (incobotulinumtoxinA); have a skin infection at the planned
injection site. Tell your doctor about all your muscle or nerve conditions, such as ALS or Lou
Gehrigâ€TMs disease, myasthenia gravis, or Lambert-Eaton syndrome, as you may be at
increased risk of serious side effects including difficulty swallowing and difficulty breathing from
typical doses of BOTOX® Cosmetic. Tell your doctor about all your medical conditions,
including: plans to have surgery; had surgery on your face; weakness of forehead muscles:
trouble raising your eyebrows; drooping eyelids; any other abnormal facial change; are pregnant
or plan to become pregnant (it is not known if BOTOX® Cosmetic can harm your unborn
baby); are breast-feeding or plan to (it is not known if BOTOX® Cosmetic passes into breast
milk). Tell your doctor about all the medicines you take, including prescription and
nonprescription medicines, vitamins, and herbal products. Using BOTOX® Cosmetic with
certain other medicines may cause serious side effects. Do not start any new medicines until
you have told your doctor that you have received BOTOX® Cosmetic in the past. Tell your
doctor if you have received any other botulinum toxin product in the last 4 months; have
received injections of botulinum toxin such as Myobloc®, Dysport®, or Xeomin® in the past
(tell your doctor exactly which product you received); have recently received an antibiotic by
injection; take muscle relaxants; take an allergy or cold medicine; take a sleep medicine; take
aspirin-like products or blood thinners. Other side effects of BOTOX® Cosmetic include:
discomfort or pain at the injection site; headache; and eye problems: double vision, blurred
vision, drooping eyelids, and swelling of your eyelids.
I take full liability and responsibility for any and all risks, undesired outcomes, or adverse events
associated with the injections and will not hold the providers or liable for any unfavorable
outcome or adverse event. I release Sei Tu Bella Aesthetics LLC, owners, and medical staff
from liability associated with the procedure. This consent form is freely and voluntarily executed
and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators,
successors and assigns . I relieve Heather Merlo, FNP-C, APRN, Medical Director Dr.
Fernando Jara and Sei Tu Bella Aesthetics LLC, from all legal action pertaining to this
treatment.

Telemedicine
I understand that my Provider has elected to utilize telehealth and online communication
services to conduct virtual examinations and manage my care plan. This may include 1)
electronic consents and questionnaires delivered to my secure
Patient Portal and required to be completed prior to my appointment 2) email communications
regarding my appointment and login information, and 4) participating in my exam via two-way,
live-streamed, video consultations for new and existing patients via a HIPAA-compliant portal.
Authorization to Evaluate Patient via Telehealth
I hereby consent to communicate by cell, e-mail, and online with my Provider so as to arrange
and conduct virtual consultations, telemedicine/telehealth, and any other purposes deemed by
my provider to be appropriate while I am receiving medical and aesthetic services.
As announced by the US Department of Health & Human Services (“HHS”) on March 17, 2020,
I understand my Provider is now authorized to use non-public facing audio and/or video
communication technology to provide telehealth, whether or not related to COVID-19, on an
acceptable non-public facing platform. I accept that even authorized non-public facing third-party
applications potentially introduce privacy risks, but my provider will enable all available
encryption and privacy modes when using these applications.
Right to Withdraw Consent
I understand that I have the right to revoke this authorization in writing at any time, but if I do so
it will have no effect on any actions taken prior to my revocation. Unless and until I revoke this
authorization, it will exist in perpetuity from the date written below. I understand that I may refuse
to sign this authorization and such refusal will have no effect on the medical treatment I receive
from my Provider.
I release and discharge my Provider, the telehealth software portal and all parties acting under
my Provider’s license and authority from any telehealth medical privacy claims I might otherwise
have had prior to HHS’s March 17, 2020 notification. I certify that I have read this Authorization
and Release and fully understand its terms.
I have read the above Authorization & Release and consent to the use of Telehealth services.

Telemedicine
I understand that my Provider has elected to utilize telehealth and online communication
services to conduct virtual examinations and manage my care plan. This may include 1)
electronic consents and questionnaires delivered to my secure
Patient Portal and required to be completed prior to my appointment 2) email communications
regarding my appointment and login information, and 4) participating in my exam via two-way,
live-streamed, video consultations for new and existing patients via a HIPAA-compliant portal.
Authorization to Evaluate Patient via Telehealth
I hereby consent to communicate by cell, e-mail, and online with my Provider so as to arrange
and conduct virtual consultations, telemedicine/telehealth, and any other purposes deemed by
my provider to be appropriate while I am receiving medical and aesthetic services.
As announced by the US Department of Health & Human Services (“HHS”) on March 17, 2020,
I understand my Provider is now authorized to use non-public facing audio and/or video
communication technology to provide telehealth, whether or not related to COVID-19, on an
acceptable non-public facing platform. I accept that even authorized non-public facing third-party
applications potentially introduce privacy risks, but my provider will enable all available
encryption and privacy modes when using these applications.
Right to Withdraw Consent
I understand that I have the right to revoke this authorization in writing at any time, but if I do so
it will have no effect on any actions taken prior to my revocation. Unless and until I revoke this
authorization, it will exist in perpetuity from the date written below. I understand that I may refuse
to sign this authorization and such refusal will have no effect on the medical treatment I receive
from my Provider.
I release and discharge my Provider, the telehealth software portal and all parties acting under
my Provider’s license and authority from any telehealth medical privacy claims I might otherwise
have had prior to HHS’s March 17, 2020 notification. I certify that I have read this Authorization
and Release and fully understand its terms.
I have read the above Authorization & Release and consent to the use of Telehealth services.

Treatment Consent Form The SaltFacial®
I, consent to undergo The SaltFacial® treatment as described to me by my skincare
professional. It has been explained to me that The SaltFacial® treatment is a safe, 3- step
process comprised of Step (1): Sea Salt Resurfacing, Step (2): Aesthetic Ultrasound, and Step
(3): LED Phototherapy.
It has been explained to me and I understand that although results may be seen with as little as
one treatment, a series of 4 to 8 treatments may be recommended based on my skin care goals.
The SaltFacial® is considered a non-invasive treatment, meaning it does not break the skin
barrier. Because of this, complications are rare, however it has been explained that I may
experience some post-treatment redness, swelling, sloughing, and flaking of the treated area. I
understand this is a normal response that can last for as little as a few minutes or up to several
days following treatment. My skincare professional has explained the treatment expectations and
I am in full understanding of this.
For more aggressive treatments, post-treatment scabbing may occur. This more aggressive type
of treatment may be performed if my skincare professional has recommended it based off my
desired treatment goals. Aftercare instructions for this type of treatment have been explained to
me and are fully understood.
I acknowledge that I have provided my full medical history, including all medications and
supplements I’m currently on.
I have informed my skincare professional of any use of Accutane within the past 12 months.
I have been instructed to discontinue use of any product containing Retin-A, retinoids, retinols,
Glycolic Acid, or AHA, for 3 to 5 days PRE-treatment and 3 to 5 days POST-treatment. I
acknowledge that my skincare professional has answered all of my questions, and the treatment
has been explained to my satisfaction.
The SaltFacial®
It has been explained that photos will be taken before and after treatment to track my progress. I
understand these photos will remain the property of this office and will not be used for any other
purpose unless I agree to release them for use.
Photo Release
I agree to release my photos to my provider to use for promotional purposes, and for possible
submission to the manufacturer to use for promotional purposes. It has been explained that
even if the photos are chosen for use, my identity will be kept private and secure.
The SaltFacial®
I understand that the treatment may involve risks of complication or injury from both known and
unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been
candid in revealing any condition that may have a bearing on this procedure.
I consent and authorize Sei Tu Bella Aesthetics , LLC, and it’s affiliates to perform the procedure
listed on me. I certify that I have read this entire informed consent and I understand and agree to
the information provided in the form. My questions regarding the procedure have been answered
satisfactorily. I hereby release Heather Merlo, APRN, FNP-C, Medical Director Dr. Fernando
Jara, Sei Tu Bella Aesthetics LLC from all liabilities associated with this procedure. This consent
is valid for all of my
treatments in the future as well.

Pronox anesthesia
Consent Form & Contraindications for Administration of Nitrous Oxide for Pain & Anxiety with
the PRO-NOX system during Aesthetic Procedures
I hereby authorize Sei Tu Bella Aesthetics and staff to provide me with Nitrous Oxide through the
PRO-NOX system for the purpose of pain and anxiety control during my procedure.
PRO-NOX is a self-administered (under the supervision of medically trained staff), quick onset,
fixed 50% nitrous and 50% oxygen pain management system with short duration of effect. It is
generally metabolized and “out of your system” (you are back to normal) within minutes of
discontinuing, and therefore you are able to regain complete mental and physical function
quickly and drive home.
The risks and benefits of inhaled nitrous oxide for pain and anxiety control have been explained
to me as have alternative forms of pain control options. Although no severe complications have
been reported with this device and type of analgesia, the risks could include headache,
euphoria, decreased mental and physical awareness and control, device malfunction and
potential overdose, failure of effect, and other unforeseen problems. We have seldom seen any
of these problems but are required to disclose them.
*If you have been diagnosed with a severe breathing condition, you should consult your doctor
before using Pro-Nox.
I understand that some possible side effects of nitrous oxide include: dizziness, nausea, lightheadedness, and unsteadiness. I understand that I should wait 10 minutes after the last use of
nitrous oxide before driving a car or operating any type of machinery.
I understand that using nitrous oxide may make me unsteady and that if need to get off the
procedure table, I will do so only with assistance.
I agree to hold the mouthpiece and inhale the nitrous oxide/oxygen gas mix without assistance
from others and only as needed through the procedure to maintain my comfort level.
I understand that nitrous oxide has been safely used throughout the world for pain and anxiety
management for many decades, and continues to be used worldwide today.
I also understand that the risks for nitrous oxide use are the same risks that exist for virtually all
other pain-relieving medications that I may choose to use during my procedure.
I understand that there are several contraindications for use of Nitrous Oxide through the PRONOX system. They are listed below.
CONTRAINDICATIONS Pregnancy ✨
Hypersensitivity to nitrous oxide mixtures ✨
✨ Artificial, traumatic or spontaneous pneumothorax
✨ Air embolism
✨ Middle ear occlusion, ear infection
✨ Eye Surgery with intra-ocular gas injection within
✨ Decompression sickness
✨ Severe abdominal distension secondary to intra-abdominal air / intestinal obstruction
✨ Inability of patient to follow directions
✨ Inability of patient to hold own delivery device (mouthpiece or mask)
I acknowledge that I do not have any of these conditions and consent to the use of Pro-Nox for
my procedure today and in the future.
I understand, agree to the above, and wish to use the PRO-NOX nitrous oxide system during my
procedure and consent to the self-administration of the gas provided to me by the medical
director and their medically trained staff members.
the last 6 weeks

I understand that the treatment may involve risks of complication or injury from both known and
unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been
candid in revealing any condition that may have a bearing on this procedure.
I consent and authorize Sei Tu Bella Aesthetics , LLC, and it’s affiliates to perform the procedure
listed on me. I certify that I have read this entire informed consent and I understand and agree to
the information provided in the form. My questions regarding the procedure have been answered
satisfactorily. I hereby release Heather Merlo, APRN, FNP-C, Medical Director Dr. Fernando
Jara, Sei Tu Bella Aesthetics LLC from all liabilities associated with this procedure. This consent
is valid for all of my
treatments in the future as well.

PDO Threads
Patient Consent Form for MINT PDO procedure
The procedure:
MINT, a patently-molded PDO thread, will be used in a minimally invasive procedure to target
sagging jowls, nasolabial folds, marionette lines, unwanted mid-face wrinkles, sagging neckline,
undefined jawlines, etc. to pull up the targeted areas and achieve a desired look.
Complications:
Relapse
Despite the thread effectively lifting areas listed above, over time and as the patient ages,
wrinkles and sagging will recur.
Infection
For prevention of infection and precautionary measure, the patient will receive a prescription for
antibiotics to be taken as directed by the doctor.
Bleeding & Bruising
Like any other procedure, there is a possibility of bleeding and bruising, but it will subside after a
couple days and 1-2 weeks respectively.
Scars
Should an incision be made during the procedure, a scar may result, but it will typically be made
in the hair line to avoid showing (speak to your doctor if an incision will be made, typically no
incisions are made).
Discomfort
Due to threads being placed in the skin, there may be discomfort in the area for several days
after the procedure, but will lessen over time. Pain and discomfort can be managed by taking
ibuprofen (ex. Motrin, Advil, etc.).
Disorder of face movement
This is rare, but depending on the pulling within the SMAS (superficial musculoaponeurotic
system) layer, it can affect a branch of the facial nerve and can cause disorders in facial
movements, however this typically recovers over time.
Skin necrosis
This may occur if blood circulation is not sufficient.
Dimpling and bunching
Dimpling and bunching may occur due to the barbed threads being placed inside the skin,
however this can be massaged out by the provider.
Medication will be given on-site and explained: Cephalosporin antibiotics
Non-steroidal pain medicine (NSAID, like Motrin)
I have been fully informed by the provider/provider’s staff/MINT manufacturer staff regarding the
procedure, its possible side-effects, and post-op care, which are listed, but not limited to the
articles listed above. Should there be any questions regarding the procedure, I, the patient, am
responsible to ask questions during the consultation for any additional information that may not
be listed on this form. I relieve Heather Merlo, APRN, FNP-C, Medical Director Dr. Fernando
Jara and Sei Tu Bella Aesthetics LLC, from all legal action pertaining to this treatment.

TONE Informed Consent
PATIENT NAME _____________________________________________________________
TREATMENT SITES ___________________________________________________________
I DULY AUTHORIZE _____________________________ TO PERFORM TONE TREATMENT.
I understand that the device being used for muscle tone improvement of which I am consenting
to be a patient receiving TONE treatment.
I understand that clinical results may vary depending on individual factors, including but not
limited to medical history, skin type, patient compliance with pre- and post- treatment
instructions, and individual response to treatment.
I understand that there is a possibility of short-term effects such as reddening, mild burning,
pain, swelling, muscles spasm, and temporary discoloration of the skin, as well as the possibility
of rare side effects such as treatment area infection, scarring and permanent discoloration.
These effects have been fully explained to me _______ (patient’s initials).
I understand that treatment with this system involves a series of treatments and the fee structure
has been fully explained to me _______ (patient’s initials).
I certify that I have been fully informed of the nature and purpose of the procedure, expected
outcomes and possible complications, and I understand that no guarantee can be given as to
the final result obtained. I am fully aware that my condition is of cosmetic concern and that the
decision to proceed is based solely on my expressed desire to do so.
I confirm that I have informed the staff regarding any current or past medical condition, disease
or medication taken.
I consent to the taking of photographs and authorize their anonymous use for the purposes of
medical audit, education and promotion.
I agree to waive, release, discharge, and covenant not to sue Invasix, Inc. d/b/a InMode
(“InMode”) and its employees, agents, and representatives, from any liability, loss, cost, damage,
expense, claim or lawsuit whatsoever for any and all injury, loss, illness, harm, cost, expense, or
damage related to the treatment, including any negligent acts or
conduct by InMode and its agents, employees, and/or representatives (collectively, “Claims”).
I certify that I have been given the opportunity to ask questions and that I have read and fully
understand the contents of this consent form.
I understand that the treatment may involve risks of complication or injury from both known and
unknown causes, and I freely assume those risks. Prior to
receiving treatment, I have been candid in revealing any condition that may have a bearing on
this procedure.
I consent and authorize Sei Tu Bella Aesthetics , LLC, and it’s affiliates to perform the procedure
listed on me. I certify that I have read this entire informed consent and I understand and agree to
the information provided in the form. My questions regarding the procedure have been answered
satisfactorily. I hereby release Heather Merlo, APRN, FNP-C, Medical Director Dr. Fernando
Jara, Sei Tu Bella Aesthetics LLC from all liabilities associated with this procedure. This consent
is valid for all of my
treatments in the future as well.

Consent for VTONE
Patient name: ______________________________Treatment Sites: vaginal canal
I duly authorize Sei Tu Bella Aesthetics to perform the VTONE treatment.
I understand that the VTONE is an EMS (Electrical Muscle Stimulation) device used for intra
vaginal treatment providing electrical stimulation and neuromuscular re- education for the
purpose of rehabilitation of weak pelvic floor muscles for the treatment of stress, urge, and
mixed urinary incontinence in women. It has been explained to me that although EMS
treatments has been very effective there is no guarantee that I will benefit from this treatment. I
understand the most common side effects and complications from this treatment are the
following:
1. Pain: you may experience pain during or after the procedure. If you feel significant discomfort
after the treatment, you may use over the counter pain medications after the procedure.
2. Swelling: there may be swelling in the treatment areas after the treatment which can last up to
one week in duration.
3. Skin irritation and burns: you may experience a burn which can be mild, moderate or severe
to different degrees in
the treatment area. Minor burns generally heal without difficulty but more severe burns, though
rate, can lead to
scarring, sensory or pigmentary changes.
4. Scarring: the risk of this complication is minimal but it can occur whenever the surface of the
skin is disrupted. Strict
adherence to all post-operative instructions will minimize the possibility of this occurring.
5. Allergic reactions: it is possible to experience an allergic reaction to an anesthetic, topical
cream or oral medication.
6. Herpes Eruption: it is possible, even with antiviral prophylaxis, to experience a herpes
eruption if you are an HSV
carrier. Inform your doctor immediately if you experience pain, skin eruptions or blistering posttreatment so that
the proper treatment can be initiated.
7. Infection: this treatment has the potential to cause skin damage, so infection is possible.
Infection is unlikely, but can
be life-threatening if it does occur and is left untreated; signs and symptoms of infection are:
redness, fever, pain, pus and swelling. Should infection occur, you should contact you doctor for
immediate evaluation and treatment.
It is important that you tell your doctor if you experience any of these side effects.
I understand that clinical results may vary depending on individual factors, including but limited
to medical history, skin type, patient compliance with pre/post treatment instructions, and
individual response to treatment.
I certify that I have been fully informed of the nature and purpose of the procedure, expected
outcomes and possible complications, and I understand that no guarantee can be give as to the
final result obtained. I am fully aware that my condition is of cosmetic concern and that the
decision to proceed is based solely on my expressed desire to do so.
I confirm that I have informed the staff regarding any current or past medical condition, disease
or medication taken. I confirm that I have had an up-to-date normal PAP test and that I have
communicated these results.
I consent to the taking of photographs and authorize their anonymous use for the purpose of
medical audit, education and promotion.
I certify that I have been given the opportunity to ask questions and that I have read and fully
understand the contents of this consent form.
I understand that the treatment may involve risks of complication or injury from both known and
unknown causes, and I freely assume those risks. Prior to
receiving treatment, I have been candid in revealing any condition that may have a bearing on
this procedure.
I consent and authorize Sei Tu Bella Aesthetics , LLC, and it’s affiliates to perform the procedure
listed on me. I certify that I have read this entire informed consent and I understand and agree to
the information provided in the form. My questions regarding the procedure have been answered
satisfactorily. I hereby release Heather Merlo, APRN, FNP-C, Medical Director Dr. Fernando
Jara, Sei Tu Bella Aesthetics LLC from all liabilities associated with this procedure. This consent
is valid for all of my
treatments in the future as well.

I,
___________________________________, authorize my Sei Tu Bella Aesthetics provider or
advanced practice clinician (s) and/or whomever may be designated as the medical assistant(s),
to help me in my weight reduction efforts. I understand that my program may consist of a
balanced deficit diet, a regular exercise program, instruction in behavioral modification
techniques, and may involve the use of appetite suppressant medications. Other treatment
options may include a very low caloric diet, or a protein supplemented diet. I further understand
that if appetite suppressants are prescribed, they may be used for durations exceeding those
recommended in the medication package insert. It has been explained to me to my complete
satisfaction that these medications have been used safely and successfully in private medical
practices as well as in academic centers for periods exceeding those recommended in the
medication product literature.
I have been provided a list of the medications that will be apart of my weight loss problem and
have the means to review various side effects, medication interactions, adverse effects ext
regarding the medication and I have been provided for my weight loss journey. I understand that
it is my responsibility to review any new treatment plan with the primary care provider of choice.
I understand that results of the program are not guaranteed and the program is non refundable.
I understand that any medical treatment may involve risks as well as the proposed benefits. I
also understand that there are certain health risks associated with remaining overweight or
obese. Risks associated with remaining overweight are tendencies to have high and increasing
higher blood pressure, diabetes, heart attack and heart disease, arthritis of the joints including
hips, knees, feet and back, sleep apnea, and sudden death. I understand that these risks may
be modest if I am not significantly overweight, but will increase with additional weight gain.
I understand that much of the success of the program will depend on my efforts and that there
are no guarantees or assurances made to me that the program will be successful. I also
understand that obesity may be a chronic, life-long condition that may require drastic changes in
eating habits and permanent changes in behavior to be treated successfully.
I understand that failing to show up for an appointment I have scheduled, without calling or
contacting Sei Tu Bella Aesthetics ahead of time, represents a disruption to
operation of the clinic. Failure to show up (“No-Show”) for a pre appointed Follow Up Visit, or ‐
failure to cancel at least one full business day prior to a scheduled visit will result in need to pay
for the missed visit and pre-pay the next Medical Weight Loss Visit.
I have read and fully understand this consent form and “no show” policy. I have had all of my
questions answered to my complete satisfaction. I have been given all the time that I need to
carefully read and understand this form.
________ (Initials) By my initials, I acknowledge that I have had an opportunity to review Sei Tu
Bella Aesthetics General Consent for Treatment Policy and also acknowledge that I should
request a copy, a copy will be provided to me.
Signed,
Patient Full Name: _______________________________________ Date:
__________________ (Or person and relationship with authority to consent for the patient)have
been provided a copy of Notice of Privacy Practices at Sei Tu Bella Aesthetics
I understand that the treatment may involve risks of complication or injury from both known and
unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been
candid in revealing any condition that may have a bearing on this procedure.
I consent and authorize Sei Tu Bella Aesthetics , LLC, and it’s affiliates to perform the procedure
listed on me. I certify that I have read this entire informed consent and I understand and agree to
the information provided in the form. My questions regarding the procedure have been answered
satisfactorily. I hereby release Heather Merlo, APRN, FNP-C, Medical Director Dr. Fernando
Jara, Sei Tu Bella Aesthetics LLC from all liabilities associated with this procedure. This consent
is valid for all of my
treatments in the future as well.