AESTHETICS BY ANGELA AA LLC
COMPREHENSIVE INFORMED CONSENT, ENTITY ACKNOWLEDGMENT & TREATMENT AUTHORIZATION
| IMPORTANT ENTITY NOTICE: Your clinical provider is Aesthetics by Angela AA LLC, a business and clinical entity that is separate and independent from Nyah Med Spa. Nyah Med Spa supplies facility space and non-clinical administrative support only. |
Patient Information
Provider Identification
| Entity |
Aesthetics by Angela AA LLC |
| Provider |
Angela Smith Austin |
| Direct treatment contact |
706-248-7469 |
Purpose and Scope of This Form
This is a master informed-consent form covering the services described in this document. The patient does not need to select or initial a service category on this form. Before any covered service is performed, the treating clinician must discuss that service with the patient and document the exact product, medication, strength, dose, route, treatment area, device settings, peel type, and other visit-specific details in the treatment record. Signing this form does not require the patient to undergo any service. The patient may withdraw consent before a service begins and may decline any service without losing access to other appropriate care.
1. Separate Clinical Entity and Allocation of Responsibilities
| CLINICAL RELATIONSHIP: All medical and clinical services covered by this form are provided through Aesthetics by Angela AA LLC and its authorized clinicians, under the oversight and protocols of Aesthetics by Angela AA LLC's separately retained medical director. |
1. Aesthetics by Angela AA LLC is completely separate from Nyah Med Spa. It maintains its own clinical operations, medical oversight, treatment protocols, patient records, consents, clinical decision-making, and professional responsibility for the services it provides.
2. Aesthetics by Angela AA LLC uses its own medical director. That medical director is not Nyah Med Spa's medical director. Nyah Med Spa's medical director does not evaluate, prescribe for, direct, supervise, or establish treatment plans for patients of Aesthetics by Angela AA LLC unless a separate written clinical arrangement is lawfully established and disclosed to the patient.
3. Aesthetics by Angela AA LLC and its medical director or other authorized prescriber are solely responsible for medical screening, good-faith or required clinical examinations, diagnosis when applicable, determining candidacy, ordering or prescribing, selecting products and devices, treatment plans, medication choice, dosage, route, injection technique, device settings, follow-up, complication management, referrals, and all other clinical decisions.
4. Nyah Med Spa's role is limited to supplying facility space and non-clinical administrative support. Administrative support may include scheduling assistance, non-clinical communications, room access, and clerical or payment-processing support performed for Aesthetics by Angela AA LLC. Nyah Med Spa does not select patients, diagnose conditions, prescribe, recommend a clinical treatment plan, choose products, determine dose or device settings, perform clinical supervision, or direct treatment.
5. Any clinical question, adverse event, medication question, refill request, treatment-plan concern, or request for medical records must be directed to Aesthetics by Angela AA LLC by calling Angela Smith Austin directly at 706-248-7469. A non-clinical Nyah Med Spa team member may route a message but cannot provide clinical advice.
6. The fact that treatment occurs at a Nyah Med Spa location, is scheduled with administrative assistance, or is processed through shared non-clinical systems does not change the identity of the clinical provider. The patient's provider for any covered service remains Aesthetics by Angela AA LLC.
Patient initials confirming entity separation:
2. General Informed-Consent Acknowledgments
• I have provided complete and accurate information about my health history, allergies, medications, supplements, prior procedures, pregnancy or breastfeeding status, and any recent illness or infection.
• Before each service is performed, its nature and purpose, expected benefits, material risks, reasonable alternatives (including no treatment), recovery expectations, and relevant off-label or compounded-product status will be explained to me in understandable language.
• Cosmetic and wellness treatments are not exact sciences. No promise or guarantee has been made about a particular result, duration, weight change, degree of fat reduction, skin response, or absence of complications.
• Some risks may be rare, delayed, permanent, or not presently known. Additional treatment, medication, referral, emergency care, hospitalization, corrective procedures, or surgery may be required at my expense, subject to applicable law and written financial policies.
• I will follow pre- and post-treatment instructions and promptly report unexpected symptoms. Failure to follow instructions may increase risk or reduce effectiveness.
• I may ask questions at any time and may stop or postpone treatment before it begins. A clinician may also postpone or refuse treatment if it is not clinically appropriate.
3. General Contraindications and Precautions
I understand that treatment may be delayed, modified, or declined based on clinical judgment, including for active infection, open wounds, uncontrolled medical conditions, bleeding disorders, immune compromise, allergy to a product component, recent procedures, unrealistic expectations, inability to follow aftercare, or pregnancy/breastfeeding when safety is uncertain. I will disclose anticoagulants, NSAIDs, supplements that affect bleeding, isotretinoin history, implanted devices, autoimmune disease, neuromuscular disease, seizure history, cold sores, keloid tendency, and prior adverse reactions.
4. Neurotoxin Injections
Purpose: Temporary reduction in muscle activity to soften expression lines or address another clinician-discussed indication. Products may include botulinum toxin type A products such as Botox, Dysport, Jeuveau, Xeomin, Daxxify, or another specifically documented product. Uses outside an FDA-approved indication or treatment area will be identified as off-label.
Material risks
• Pain, bleeding, bruising, swelling, redness, itching, headache, tenderness, infection, or flu-like symptoms.
• Temporary or prolonged weakness of intended or nearby muscles; facial asymmetry; undesired expression; difficulty smiling, speaking, chewing, swallowing, whistling, or using a straw.
• Eyelid or brow droop, dry or watery eye, inability to fully close the eye, double vision, or other visual symptoms. Prescription eye drops or other treatment may be considered by the responsible clinician when appropriate.
• Unsatisfactory, incomplete, uneven, or short-lived effect; need for additional treatment; reduced effect or antibody formation with repeated exposure.
• Rare spread of toxin effect causing generalized weakness, swallowing or breathing difficulty, or other serious symptoms requiring immediate medical attention.
• Allergic reaction, nerve injury, scarring, pigment change, or other rare and unforeseen complications.
5. Dermal Filler and Biostimulator Injections
Purpose: Restore or alter volume, contour features, soften lines, or stimulate tissue response using hyaluronic-acid filler, calcium hydroxylapatite, poly-L-lactic acid, or another specifically documented filler or biostimulator. Product selection, placement, and whether use is on-label or off-label will be discussed and recorded by Aesthetics by Angela AA LLC.
Material risks
• Pain, bruising, redness, swelling, tenderness, itching, bleeding, discoloration, firmness, dryness, acne-like eruptions, infection, reactivation of cold sores, scarring, pigment change, or delayed healing.
• Lumps, nodules, granulomas, visible or palpable product, migration, asymmetry, overcorrection, undercorrection, contour irregularity, Tyndall effect, or an undesired result that may be temporary or permanent.
• Delayed inflammatory reaction, biofilm-related infection, allergic reaction, tissue injury, or need for antibiotics, steroids, aspiration, dissolution, surgical removal, or other corrective care.
• Vascular occlusion if product enters or compresses a blood vessel. This can cause severe pain, blanching or mottling, skin breakdown, tissue death, scarring, stroke-like injury, retinal artery occlusion, partial or permanent blindness, or other permanent injury. Urgent treatment may not reverse the outcome.
6. Hyaluronidase / Filler Dissolution
I authorize hyaluronidase when separately discussed and clinically indicated to dissolve hyaluronic-acid filler, including for suspected vascular compromise, overcorrection, asymmetry, nodules, or an undesired result. I understand that it does not dissolve all filler types and may dissolve more filler than intended.
• Pain, bruising, swelling, redness, itching, uneven or incomplete dissolution, loss of desired volume, skin laxity, contour change, and need for repeat treatment.
• Allergic reaction, hives, swelling, breathing difficulty, anaphylaxis, infection, or rare unforeseen effects.
• Emergency administration may be recommended when delay could increase the risk of tissue or vision injury. Separate emergency evaluation may still be required.
7. PCDC Lipolysis / Lipo-Dissolve Injections
Purpose: Injection of phosphatidylcholine/deoxycholate (PCDC), deoxycholic acid, or another specifically documented lipolytic preparation to reduce a localized fat deposit. Results are variable, multiple sessions may be required, and this is not a weight-loss treatment. The clinician will disclose whether the exact drug, formulation, source, indication, and treatment area are FDA-approved, off-label, or compounded.
| IMPORTANT: Compounded PCDC preparations and many treatment areas commonly described as 'lipo dissolve' are not FDA-approved. Compounded drugs are not reviewed by FDA for safety, effectiveness, or manufacturing quality in the same manner as approved drugs. The exact product and status must be documented before treatment. |
Material risks
• Burning, pain, tenderness, redness, bruising, warmth, swelling, itching, numbness, firmness, nodules, drainage, or prolonged inflammation.
• Uneven fat loss, contour irregularity, asymmetry, inadequate response, skin laxity, hyperpigmentation or hypopigmentation, scarring, or need for additional/corrective treatment.
• Infection, ulceration, skin breakdown, tissue death, nerve injury, muscle injury, vascular injury, prolonged numbness, or injury to structures beneath or near the treatment area.
• When used near the jaw or neck: temporary or persistent weakness affecting the smile, difficulty swallowing, or other nerve-related effects.
• Allergic reaction, systemic symptoms, or unknown risks associated with off-label or compounded use.
8. PDGF / Regenerative Injections
Purpose: Injection or application of a platelet-derived growth factor (PDGF), platelet-derived, biologic, recombinant, or other regenerative product for a clinician-discussed cosmetic or hair-related purpose. The exact product, source, processing method, regulatory status, intended use, and whether the use is off-label will be disclosed and documented before treatment. Results are not guaranteed and evidence may vary by product and indication.
Material risks
• Pain, bleeding, bruising, swelling, redness, itching, tenderness, infection, inflammation, rash, acne-like reaction, pigment change, scarring, or delayed healing.
• Lumps, nodules, granuloma, uneven response, no response, worsening of the treated concern, temporary shedding when used on the scalp, or need for repeat treatment.
• Allergic or immune reaction, contamination or transmission risk depending on product source and handling, vascular or nerve injury, tissue injury, or unknown long-term effects.
• Risks unique to the specific product or delivery method, which must be reviewed with me before use.
9. Weight-Management Medications and Injections
Purpose: Medical weight management using a medication selected and prescribed by an authorized Aesthetics by Angela AA LLC clinician or its independently contracted prescriber. This may include a GLP-1 receptor agonist, dual GIP/GLP-1 medication, or another specifically documented medication. The prescription, dose, titration, route, monitoring, refill decisions, and management of side effects belong exclusively to Aesthetics by Angela AA LLC and its medical director/prescriber, not Nyah Med Spa.
Potential benefits and alternatives
Potential benefits may include reduced appetite, improved metabolic measures, or weight reduction. Alternatives include nutrition and activity changes alone, behavioral treatment, other approved medications, specialist care, bariatric procedures, or no treatment.
Material risks
• Nausea, vomiting, diarrhea, constipation, reflux, abdominal pain, bloating, decreased appetite, dehydration, headache, fatigue, dizziness, injection-site reactions, or gallbladder disease.
• Low blood sugar, especially with insulin or certain diabetes medicines; kidney injury related to dehydration; delayed stomach emptying; worsening gastroparesis; ileus or bowel obstruction; pancreatitis; allergic reaction; or serious illness requiring urgent care.
• Loss of lean mass, nutritional deficiency, hair shedding, mood or eating-pattern changes, medication interactions, weight regain after discontinuation, or inadequate response.
• Potential thyroid C-cell tumor risk identified in animal studies for certain medications and contraindications based on personal or family history. The prescriber will review medication-specific warnings, including pregnancy precautions and any boxed warning, before prescribing.
• Risks may differ if a compounded medication is prescribed. A compounded drug is not FDA-approved and is not reviewed by FDA for safety, effectiveness, or manufacturing quality in the same manner as an approved drug. The dispensing pharmacy and exact formulation must be identified in the medication record.
I will promptly report severe or persistent abdominal pain, repeated vomiting, inability to keep fluids down, signs of dehydration, jaundice, allergic symptoms, severe constipation or abdominal distension, symptoms of low blood sugar, pregnancy, or any concerning change. I understand that medication-specific consent and education may also be required.
10. Wellness Injections
Purpose: Intramuscular, subcutaneous, or other clinician-directed administration of a specifically ordered wellness medication or nutrient, such as vitamin B12, lipotropic compounds, NAD-related products, or another documented preparation. The exact ingredients, indication, route, dose, source, regulatory status, and expected benefit will be reviewed before administration. General wellness claims are not guarantees of benefit.
• Pain, bleeding, bruising, swelling, redness, infection, abscess, scarring, pigment change, nerve injury, blood-vessel injury, fainting, or injection-site tissue damage.
• Headache, nausea, flushing, dizziness, fatigue, cramping, chest discomfort, rapid heartbeat, allergic reaction, medication interaction, or effects unique to the specific ingredient.
• Incorrect, excessive, or cumulative exposure; laboratory abnormalities; delayed diagnosis if injections are used instead of appropriate medical evaluation; and unknown risks for compounded or non-approved formulations.
Peptide Injections Consent
Peptide injections covered by this form may include an FDA-approved peptide medication or a patient-specific compounded peptide preparation lawfully prescribed for a documented purpose. Before administration, the exact peptide, source, strength, dose, route, intended purpose, expected benefits, reasonable alternatives, and regulatory status will be explained and documented. Benefits are not guaranteed. I understand that compounded and other non-approved peptide products are not reviewed by FDA for safety, effectiveness, or manufacturing quality in the same manner as FDA-approved drugs.
• Injection-site pain, bleeding, bruising, redness, swelling, infection, abscess, scarring, tissue injury, or nerve or blood-vessel injury.
• Allergic or immune reaction, including rash, hives, swelling, breathing difficulty, or anaphylaxis. Peptide aggregation, impurities, or contamination may increase immune-response and safety risks.
• Product-specific or systemic effects such as headache, nausea, dizziness, flushing, fatigue, appetite or blood-sugar changes, fluid changes, altered heart rate or blood pressure, hormonal or organ effects, medication interactions, or worsening of an underlying condition.
• Incorrect dosing, inadequate response, loss of effect, laboratory abnormalities, risks related to storage or preparation, and other short- or long-term risks that may be uncommon, delayed, or not yet known.
I consent only to a peptide injection that has been specifically identified, ordered or prescribed, discussed with me, and documented in my treatment record. I will disclose my medical conditions, allergies, pregnancy or breastfeeding status, and all medications and supplements. I understand that a product-specific consent or additional monitoring may still be required before treatment.
11. Microneedling
Purpose: Controlled creation of microscopic channels in the skin to improve the appearance of texture, scars, fine lines, discoloration, or another clinician-discussed concern. The device, needle depth, treatment area, and any topical or applied product will be documented. Results vary and multiple sessions may be needed.
Material risks
• Pain, pinpoint bleeding, redness, swelling, tightness, dryness, flaking, itching, bruising, crusting, tenderness, or temporary worsening of the treated concern.
• Infection, reactivation of cold sores, acne flare, prolonged inflammation, delayed healing, scarring, keloid formation, broken capillaries, or textural change.
• Post-inflammatory hyperpigmentation, hypopigmentation, uneven pigment, photosensitivity, or greater risk with recent tanning or inadequate sun protection.
• Allergic or irritant reaction, granuloma, tattoo ink or cosmetic pigment alteration, and risks from any serum, anesthetic, biologic, or topical product introduced during treatment.
12. Radiofrequency (RF) Microneedling
Purpose: Combination of microneedling with radiofrequency energy to heat tissue for a clinician-discussed skin-tightening, texture, scar, or contour goal. The device, needle depth, energy level, pulse settings, treatment area, and operator will be documented.
Material risks
• All microneedling risks listed above, plus heat-related pain, prolonged redness or swelling, grid marks, track marks, blistering, burns, crusting, ulceration, fat loss, tissue injury, or delayed healing.
• Temporary or permanent hyperpigmentation or hypopigmentation, uneven skin texture, scarring, nerve symptoms, altered sensation, asymmetry, or an undesired contour change.
• Electrical or thermal risks and interference concerns involving certain implanted electronic or metal devices. I will disclose pacemakers, defibrillators, metal implants, and other implanted devices.
• Incomplete or uneven improvement, need for multiple sessions, or worsening of the treated condition.
13. Medical-Strength Chemical Peels
Purpose: Application of one or more chemical agents to produce controlled exfoliation for pigmentation, acne, texture, fine lines, or another clinician-discussed condition. The peel name, ingredients/strength when known, treatment area, passes or layers, endpoint, and aftercare will be documented. Peel depth and response can vary among patients.
Material risks
• Stinging, burning, warmth, pain, redness, swelling, tightness, peeling, crusting, temporary darkening, tenderness, itching, or prolonged sensitivity.
• Chemical burn, blistering, ulceration, infection, cold-sore reactivation, delayed healing, scarring, milia, acne flare, or line of demarcation.
• Post-inflammatory hyperpigmentation, hypopigmentation, uneven color, photosensitivity, or permanent pigment change, with increased risk from sun exposure, picking, incompatible products, or certain skin types and medical histories.
• Eye or mucous-membrane injury if product migrates; allergic or irritant reaction; and risks unique to the specific acid or peel formulation.
14. Pre-Treatment and Aftercare Responsibilities
Before treatment
• Follow the written instructions issued for the applicable service. Do not stop a prescribed medication unless the prescribing clinician instructs you to do so.
• Disclose blood-thinning medicines, supplements, recent dental work or vaccines when relevant, current infections, cold sores, recent tanning or sunburn, recent procedures, new diagnoses, pregnancy or breastfeeding, and any change in medications or allergies.
• Arrive without avoidable irritants, self-tanner, or active products when instructed, and eat/hydrate when instructed for the applicable service.
After treatment
• Follow the service-specific written aftercare provided by Aesthetics by Angela AA LLC. Do not rub, pick, peel, massage, apply heat, exercise, lie flat, expose the area to sun, or use active skincare except as specifically instructed for that service.
• Use sun protection and keep the treated area clean as directed. Do not perform self-treatment or use another person's prescription medication.
• Contact Angela Smith Austin directly at 706-248-7469 promptly for any treatment question or concern, including worsening pain, unusual blanching or mottling, increasing redness or swelling, drainage, fever, blistering, difficulty swallowing or breathing, eye symptoms, persistent vomiting, severe abdominal pain, neurologic symptoms, or any unexpected reaction.
| EMERGENCY WARNING: For a medical emergency, call 911 or go to the nearest emergency department. This includes trouble breathing, chest pain, stroke-like symptoms, severe allergic reaction, sudden vision change or loss, rapidly worsening severe pain, loss of consciousness, or another life-threatening concern. Then contact Angela Smith Austin directly at 706-248-7469 as soon as safely possible. |
15. Follow-Up, Complications, and Records
Aesthetics by Angela AA LLC is responsible for clinical follow-up, assessment of complications, medication decisions, referrals, and maintenance of the clinical record for services covered by this form. I authorize reasonable communication with emergency clinicians, pharmacies, laboratories, consultants, and other treating professionals when permitted by law and necessary for my care. Nyah Med Spa may provide clerical routing or facility assistance but will not make clinical decisions.
16. Financial Responsibility
I understand that these services are generally elective and may not be covered by insurance. Fees, cancellation terms, refund policies, package terms, and responsibility for follow-up or corrective care will be governed by the written financial policies presented by Aesthetics by Angela AA LLC. Administrative collection or processing by Nyah Med Spa, if any, is performed only as non-clinical support and does not make Nyah Med Spa the clinical provider.
17. Photography and Recording Authorization
Clinical photographs may be required for treatment planning, documentation, safety, and follow-up and will be maintained as part of the clinical record. Marketing use is optional and requires the separate choice below. Refusal of marketing use will not affect care.
18. Facility Role, Claims, and Non-Waivable Rights
I acknowledge that Nyah Med Spa provides facility space and non-clinical administrative support only for services rendered by Aesthetics by Angela AA LLC. Nyah Med Spa does not establish or control the treatment plan, product, prescription, dose, injection technique, device settings, clinical documentation, follow-up plan, or complication management. Clinical questions and claims concerning professional services must be directed to Aesthetics by Angela AA LLC and the involved clinician or medical director.
To the fullest extent permitted by law, I agree not to assert that Nyah Med Spa became my clinical provider solely because treatment occurred at its location or because it supplied administrative support. Nothing in this form releases any person or entity from liability that cannot lawfully be waived, excuses a licensed professional from the applicable standard of care, or limits any right or remedy that applicable law makes non-waivable.
Patient initials confirming facility-only role:
19. No Guarantee and Assumption of Inherent Risk
I understand the known and reasonably foreseeable risks described in this form and any additional risks explained for each service before it is performed. I knowingly accept the inherent risks of an appropriately performed procedure and understand that an undesired outcome or complication can occur without negligence. I understand that this acknowledgment does not eliminate the treating professional's duty to meet the applicable standard of care.
20. Dispute Resolution and Arbitration Acknowledgment
Except for any claim or remedy that cannot lawfully be subjected to pre-dispute arbitration, the patient and Aesthetics by Angela AA LLC agree that a dispute, claim, or controversy arising out of or relating to the clinical services, this consent, or the patient-provider relationship shall be resolved by binding arbitration administered under the applicable healthcare or commercial rules of the American Arbitration Association. The arbitrator, rather than a court or jury, will decide the dispute and may award any remedy available under applicable law. Venue will be in the Georgia county where the treatment occurred unless the parties agree otherwise. Each party retains the right to seek emergency injunctive relief or to report concerns to a licensing board or government agency.
By signing below, I understand that arbitration generally waives the right to have covered claims decided by a judge or jury. I have had an opportunity to ask questions and consult independent counsel before agreeing.
Patient initials specifically agreeing to arbitration:
21. Supersession and Scope
For the services covered by this form, this document supersedes prior general neurotoxin and dermal-filler consent forms between this patient and Angela Smith Austin or Aesthetics by Angela AA LLC to the extent they address the same subject matter. It does not cancel a separate privacy notice, financial policy, medication-specific consent, aftercare instruction, media release, arbitration addendum, or other document that expressly remains in effect. If a product, medication, device, or procedure has material risks not adequately addressed here, a supplemental consent must be provided before treatment.
22. Patient Certification and Voluntary Consent
By signing, I certify that I have read or had this form read to me; the covered services and applicable sections will be explained before treatment; I will have an opportunity to ask questions; and I understand the separate roles of Aesthetics by Angela AA LLC and Nyah Med Spa. I voluntarily authorize a covered service only after that service has been discussed with me and documented in the treatment record. I understand that this master consent does not require me to receive any service and that I may withdraw consent before any treatment begins.
Patient signature
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