I hereby give my consent to undergo the procedure of drug administration with the Hyaluron Pen for cosmetic purposes by Glamorous Med Spa

I confirm that I have been informed about how this procedure is preformed and the drug used: It is a sterile non-pyrogenic physiological gel based on hyaluronic acid of non-animal origin administered by a piston loaded air compression pen.

I understand that I cannot receive this treatment if I have/am:

- Non-treatable epilepsy.
- Inflammation or infection in the lip area.
- The tendency to develop hypertrophic scarring.
- Known hypersensitivity to hyaluronic acid.
- Known hypersensitivity to lidocaine or local anesthetics from the amide group.
- Porphyria.
- Diabetes.
- Autoimmune disease.
- Currently being treated with anticoagulants (blood thinners, asprin etc.).
- Blood diseases and blood coagulation problems.
- Pregnant, trying to get pregnant or are breast feeding.
- Malignant tumors.
- Under the age of 18 years old.

I am aware of side effects to include but are not limited to:

- Inflammatory reaction in the location of manipulated area (swelling, erythema, redness, etc.), which may be accompanied with itching, as well as pain due to pressing on treated area. Such an inflammatory reaction can last up to 7 days.
- The appearance of bruising and swelling.
- Administration site bleeding.
- The appearance of compaction or nodules at the administration sites.
- Coloration or discoloration of the skin in the area of the drug administration.
- Topical breakouts of herpes and cold sores if cold sore area was not treated with proper medication at least 1 week prior to procedure.

I have been informed about the main advantages and complications of this procedure. Complications include but are not limited to: various forms of allergic reactions (anaphylactic shock, Quincke's edema, fainting, collapse) post-treatment swelling, bruising and hematomas. It is important to take into account the potential risk of complications such as skin necrosis over the bridge of the nose, abscesses, granulomas of allergic reactions of immediate or delayed type after administration of hyaluronic acid or lidocaine intolerances. All of which are possible due to this kind of treatment.

I should contact my technician immediately if the duration of the inflammatory reaction to the administered site lasts for more than 7 days.

Have you ever had hepatitis?

I have informed my technician about any skin reactions and intolerances to drugs, food, products and other substances that I have along with any diseases and injuries that I have had including chronic diseases of concomitant pathology.

I have provided truthful and accurate information about my lifestyle choices, hereditary diseases, as well as about my surgical and anesthetic interventions.

I confirm that the technician: - Informed me about the way the procedure is done and the drug used for me to make an informed decision. - Gave me an opportunity to ask questions before the start of the procedure and get comprehensive information. - Gave me time to discuss the protocol of the procedure. - Gave the most complete information about the state of my health.

I give my consent for conducting this procedure by the said appointed technician. I also give my consent for taking photos and videos during the procedure and allow the technician to use said materials business and scientific purposes. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks and do not hold my technician or representing company responsible for any liabilities that may incur from having this treatment preformed. I do not hold the technician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.