Newport Cosmetic Center

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1 Shirin Afrasiabi, M.D, Inc Newport Blvd, Costa Mesa, Ca (949) Appointment: Initial. We require a valid Credit Card at the time of booking to secure your appointment Cancellation and Refund Policy: Initial. There are absolutely no refunds on any cosmetic procedure or package of procedures. There are absolutely no transfers to another party of cosmetic procedures. Any Procedures not cancelled within 24 hours prior to the scheduled appointment time will be charged as treatment time. Right of Refusal: Initial. Newport Cosmetics reserves the right to refuse treatment to any client or patient for improper conduct. Improper conduct will result in immediate termination of the treatment and the client will be billed in full. We reserve the right to define inappropriate conduct language.

2 Shirin Afrasiabi, MD, Inc Newport Blvd, Costa Mesa, Ca 92627, (949) QUOTATION FOR COSMETIC SERVICES Name: Date: I am interested in { } Laser { } Botox { } Juvederm { } Chemical Peel Areas to be treated: Total Price: Per Session For Session(s) For Session(s) Patient Signature M.D. or Agent CANCELLATION AND REFUND POLICY: INITIAL. THERE ARE ABSOLUTELY NO REFUNDS ON ANY LASER PROCEDURES OR PACKAGE OF PROCEDURES. THERE ARE ABSOLUTELY NO TRANSFERS TO ANOTHER PARTY LASER PROCEDURES.ANY PROCEDURE NOT CANCELLED WITHIN 24 HOURS PRIOR TO THE SCHEDULED APPOINTMENT TIME WILL BE CHARGED AS TREATMENT TIME

3 Shirin Afrasiabi, M.D, Inc Newport Blvd, Costa Mesa, Ca 92627, (949) Patient Information Name: Date: Address: City: State: Zip: Date of Birth: Age: Marital Status: Occupation: Home Phone: Work: Cell: In Case of an Emergency: Name of a friend or relative we can contact. Name: Relationship: Phone: Reason for Consultation: SKIN TYPE: (When exposed to the sun without protection for about one hour) I. Always burns, never tans IV. Always tans II. Always burns, sometimes tans V. Hispanic, Asian, Mediterranean III. Sometimes burns, sometimes tans VI. Black Allergies: Are you Pregnant? What medication are you currently taking (including aspirin)? Do you develop cold sores of fever blisters? Do you develop keloid scarring? Have you ever taken Accutane? If you smoke, how much? If you drink, how much Who can we thank for referring you? I understand that payment is due in full prior to beginning treatment unless other arrangements were made in writing prior to my appointment. I also understand that there are absolutely no refunds on any laser procedures or package of procedures.there are absolutely no transfers to another party of laser procedures. Any procedure not cancelled within 24 hours to the scheduled appointment will be charged as one (1) full procedure/treatment. Date Patient or responsible party s signature

4 Shirin Afrasiabi, M.D, Inc Newport Blvd, Costa Mesa, Ca 92627, (949) General Laser Consult: Laser Hair Removal Laser Collagen Laser Vein Treatment Pigmentation Removal The following factors should be considered in your decisions to undergo laser treatment Although these treatments are effective in most cases no guarantees can be made that a specific patient will benefit from treatment. The full benefit of the laser treatment may take several weeks to develop. Multiple laser treatments may be necessary to achieve desired results. It is important to protect your eyes during treatment with protective eyewear we provide. Redness and swelling may develop after each treatment. It is important to protect the treated areas form direct sun exposure. Skin texture changes, scarring or infection are possible risks. There is a risk of increased pigmentation, especially in patients with darker skin tones. To minimize the chance of a complication, it is important to follow all the pre and post procedures instruction. Laser Hair Removal: *Benefits-Cosmetic appeal, convenience, may help control ingrown hairs and folliculitis. *Alternatives- No treatment, shaving, waxing, plucking, electrolysis, depilatories Laser vein Therapy: *Benefits-Cosmetic appeal *Alternatives-No treatment, sclerotherapy, electrocautery Laser Collagen Therapy: lines *Benefits-Improved skin texture, plumping of the skin, decreased pore size, softening * Alternatives- No treatments, chemical peels, topical therapies, cryotherapy In signing this form, you are stating that you have read the consent form, and although it may have some medical terms which you which you may not completely understand, you have had the opportunity to ask questions and had them answered satisfactorily by your doctor or provider. X I understand the information presented and have had all my questions answered to my satisfaction. X I understand the potential risks, complications, benefits and alternatives to having laser treatment. X I am willing to accept the fact that there is no guarantee that this procedure will improve my condition. Type of procedure and area (s) treated

5 I request performance of the treatment described above and I agree to participate and cooperate with physicians who direct Newport Cosmetic Center. Patient Signature Date Printed Name Chemical Peel The following factors should be considered in your decisions to undergo cosmetic treatment Although these treatments are effective in most cases no guarantees can be made that a specific patient will benefit from treatment. It has been explained to me that Blue Peel RADIANCE effectively exfoliates the uppermost damaged skin layers, leaving my skin fresh, renewed, and radiant. While Blue Peel RADIANCE is formulated to be gentle; I understand I may experience a mild burning sensation during the treatment and mild peeling and redness on my journey to revealing fresh, glowing skin. Botox & Juvederm The following factors should be considered in your decisions to undergo cosmetic treatment Although these treatments are effective in most cases no guarantees can be made that a specific patient will benefit from treatment. Botox Cosmetic is a prescription medicine that is injected into muscles and used to improve the look of moderate to severe frown lines & crow s feet in adults. The full benefit of the cosmetic treatment may take several weeks to develop. Although these treatments are effective in most cases no guarantees can be made that a specific patient will benefit from treatment. Botox & Juvaderm are temporary fillers. Multiple cosmetic treatments may be necessary to achieve desired results. Redness and swelling may develop after each treatment. Botox can cause serious side effects, including problems swallowing, speaking, breathing & toxin effects, Call the office if you have any problems hours to weeks after treatment. Inform the Doctor of any muscle or nerve conditions, surgeries, prescriptions, or medications you are taking. Other side effects, include; dry mouth, discomfort or pain at the injection site, tiredness, headache, neck pain, eye problems, drooping eyelids, swelling, & dry eyes. It is important to protect the treated areas form direct sun exposure. Skin texture changes, scarring or infection are possible risks. To minimize the chance of a complication, it is important to follow all the pre and post procedures instruction

6 Juvederm Cosmetic is an injectable gel that is injected into areas of facial tissue where moderate to severe facial wrinkles and folds occur to temporarily add volume to the skin, which may give the appearance of a smoother surface. The physician will ask about your medical history to determine if you are an appropriate candidate for treatment. This product should not be used in patients that have, severe allergies, marked by history of anaphylaxis or history or presence of multiple severe allergies. A history of allergies to lidocaine or Gram-positive bacterial proteins. Juvaderm should be used with caution in patients on immunosuppressive therapy, patients who are using substances that can prolong bleeding, such as aspirin or ibuprofen, as with any injection may experience increased bruising or bleeding at injection site. Most side effects are mild to moderate in nature, and their duration is short lasting (7 days or less). The most common side effects include, redness, pain / tenderness, firmness, swelling, lumps & bumps, bruising, itching, & discoloration. As with all skin-injection procedures, there is risk of infection. X I understand the information presented and have had all my questions answered to my satisfaction. X I understand the potential risks, complications, benefits and alternatives to having cosmetic treatment. X I am willing to accept the fact that there is no guarantee that this procedure will improve my condition. Type of procedure and area (s) treated I request performance of the treatment described above and I agree to participate and cooperate with physicians who direct Newport Cosmetic Center. Patient Signature Date Printed Name

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