Dermal Fillers Informed Consent


Dermal Fillers Informed Consent Form

Dermal Fillers Informed Consent Form

(Aesthetics)

Date:

Patient Information

  • Patient Name: {{patient_first_name}} {{patient_last_name}}
  • Date of Birth: {{patient_birthdate}}

Treatment Information

I understand that I will be receiving dermal filler injections to enhance facial volume and reduce signs of aging. Dermal fillers are gel-like substances injected beneath the skin to restore lost volume, smooth lines, soften creases, or enhance facial contours.

Consent Statements

Please initial each statement:

1. I understand the nature of dermal filler treatments.

2. I understand the potential risks and benefits.

3. I have been informed of alternative treatments.

4. I understand that results are not guaranteed.

5. I will follow all post-treatment instructions.

Signatures

Patient Signature: _________________________ Date:

Provider Signature: Date:

Medical Services provided by Primary Medical of KY, P.S.C., Elite Health Services, P.A., Co., Primary Medical of IN, P.C.

Form Complete

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Miranda Adams
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Miranda Adams
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Miranda Adams
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Kimberly McKinley
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Alyssa Pumphrey
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Rima Khatib
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Kelsey Legg
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Amanda Maum
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Alyssa Pumphrey
(Awaiting Signature)

Marissa Mitchell
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Rima Khatib
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Kelsey Legg
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Amanda Maum
(Awaiting Signature)

Alyssa Pumphrey
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Marissa Mitchell
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Catherine Pusateri
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Jill Pryor
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Kathryn Salama
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Carter Sparks
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Deana Carl
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Luis Escobar
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Morgan Michels
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Jenna Meffert
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Kaylee Aebersold
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Chelsey Mcpheeters
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Kasey Gutgsell
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Lainey Hayden
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Zach Callery
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Zach Callery
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Zoe Mclaughlin
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Olivia Grass
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Phyllis White
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Phyllis White
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Renee Eldridge
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Monika Douglas
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Renee Eldridge
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Renee Eldridge
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Monika Douglas
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Renee Eldridge
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Renee Eldridge
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Monika Douglas
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Renee Eldridge
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Monika Douglas
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Monika Douglas
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Monika Douglas
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Renee Eldridge
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Monika Douglas
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Renee Eldridge
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Courtney Zurkuhlen
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Amber Zurkuhlen
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Brandon Ray
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Jill Miles
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Luis Escobar
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Karleigh Rapson
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Madison Reynolds
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Ava Peters
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Andrea Sleep
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Shireen Jameel
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Lisa Holland
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Whitley Lehman
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Jonathon Bennett
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Carly Rizzo
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Mel’Vontae Reese
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Angela Blevens
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Makenzie Barnes
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Libby Smith
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Mckenzie Schnarr
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Caroline Pender
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Tye Lewis
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Sabrina Naser
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Jordan DeJarnette
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Shelby Fuller
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Lauren Cahalan
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Riley Hostutler
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Luis Escobar
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Celia Kellicker
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Celia Kellicker
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Allyson Rodriguez
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Edvin Habibovic
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Annie Bonura
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Courtney Bell
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Angelina Brown
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Michaela Smith
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Jamie Kittle
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Jolene Barnes
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Tiffany Adams
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Tiffany Adams
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Jennifer Bame
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Jennifer Bame
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Maya Bundy
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Kacie Lambert
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Maddie Spalding
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Trinity McKinney
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Katie Scott
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Trinity McKinney
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Katie Scott
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Lyndsey Newport
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Lyndsey Newport
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Darcee Nice
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Sydney Stewart
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Carmen Mckenzie
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Carmen Mckenzie
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Sydney Stewart
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Gerri Flanagan
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Madison Rich
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Taryn Ackles
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Macauley Murphy
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Allyson Robinson
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Allyson Robinson
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Kristy Wells
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Kristy Wells
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dawn.miller749@gmail.com
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Brandy Dillard
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Brandy Dillard
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Allison Zimmerman
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Allison Zimmerman
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April Kovacs
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Ashley Larison
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Erica Harper
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Shari House
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Chrissy Crutcher
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April Kovacs
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Chrissy Crutcher
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Allison Zimmerman
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Ashley Larison
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Erica Harper
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Shari House
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Tia Humphrey
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Tiandra Puryear
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Hunter Ware
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Alyssa Freitas
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Alea Ohle
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Alea Ohle
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Zion Gisele
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Samantha Watkins
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Samantha Watkins
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Cassidy Weddle
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Samantha Watkins
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Cassidy Weddle
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Samantha Watkins
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Cassidy Weddle
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Samantha Watkins
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Cassidy Weddle
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Samantha Watkins
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Cassidy Weddle
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Samantha Watkins
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Cassidy Weddle
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Samantha Watkins
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Cassidy Weddle
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Samantha Watkins
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Cassidy Weddle
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Samantha Watkins
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Cassidy Weddle
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Samantha Watkins
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Cassidy Weddle
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Samantha Watkins
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Cassidy Weddle
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Samantha Watkins
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Cassidy Weddle
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Samantha Watkins
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Cassidy Weddle
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Samantha Watkins
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Cassidy Weddle
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Samantha Watkins
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Cassidy Weddle
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Samantha Watkins
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Cassidy Weddle
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Samantha Watkins
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Cassidy Weddle
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Samantha Watkins
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Cassidy Weddle
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Samantha Watkins
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Cassidy Weddle
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Samantha Watkins
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Cassidy Weddle
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Samantha Watkins
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Cassidy Weddle
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Samantha Watkins
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Cassidy Weddle
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Samantha Watkins
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Cassidy Weddle
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Samantha Watkins
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Cassidy Weddle
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Samantha Watkins
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Avery Hurst
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Mackenzie Davis
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Mackenzie Davis
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Mackenzie Davis
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Mackenzie Davis
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Mackenzie Davis
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Mackenzie Davis
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Mackenzie Davis
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DeAnn Knego
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Abigail Grimm
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Abigail Grimm
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Abigail Grimm
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Abigail Grimm
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Abigail Grimm
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Abigail Grimm
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Uilani Owens
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Shelby Wetterau
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Uilani Owens
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Shelby Wetterau
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Uilani Owens
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Shelby Wetterau
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Uilani Owens
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Shelby Wetterau
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Uilani Owens
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Shelby Wetterau
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Uilani Owens
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Shelby Wetterau
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Uilani Owens
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Shelby Wetterau
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Uilani Owens
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Shelby Wetterau
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Uilani Owens
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Shelby Wetterau
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Uilani Owens
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Shelby Wetterau
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Uilani Owens
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Shelby Wetterau
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Uilani Owens
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Shelby Wetterau
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Uilani Owens
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Tim Helfrich
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Jeryl Trail
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Destiny Owens
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Destiny Owens
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Destiny Owens
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Destiny Owens
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Flavia Arocha
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Flavia Arocha
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Crystal Gresham
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Olivia Bricker
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Beyonce Rodriguez
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Brittany Blankenbaker
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Ashleigh-jo Albert
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Signature Certificate
Document name: Dermal Fillers Informed Consent
lock iconUnique Document ID: 7ec940aaa76e7043147941a8d83f683509e8e6c0
Miranda Adams
Party ID: c1134a69-694b-479f-94cd-0696ac9fb955
Awaiting signature
Kimberly McKinley
Party ID: 275c7c42-4ef3-406b-af15-7ca163345464
Awaiting signature
Alyssa Pumphrey
Party ID: 11cc1382-f6f6-45ed-a9a5-48277b9f88d7
Awaiting signature
Rima Khatib
Party ID: 31e794ad-5265-402e-b86e-b78769ee1e0d
Awaiting signature
Kelsey Legg
Party ID: b15ede1e-6a7c-43f4-974e-9c1086808f70
Awaiting signature
Amanda Maum
Party ID: bcd75aa7-b4fe-4010-9ea9-252a81ec2e87
Awaiting signature
Marissa Mitchell
Party ID: 705793d2-6bff-49c0-882c-25c2b0193600
Awaiting signature
Catherine Pusateri
Party ID: 9162cf91-a8b1-42f4-9fb4-e016b7f39fbe
Awaiting signature
Jill Pryor
Party ID: 7390b97a-a0d6-401c-ba3d-496eba036238
Awaiting signature
Kathryn Salama
Party ID: c86dc69d-07f3-4add-9fcf-c4df69dd1950
Awaiting signature
Carter Sparks
Party ID: 48c19676-6c89-4d4f-ac4c-0b8e8c678e05
Awaiting signature
Deana Carl
Party ID: dda0d286-da38-4e73-9d17-1b8bf4c70fae
Awaiting signature
Luis Escobar
Party ID: 635e739d-8c7a-4179-b032-76b23dfd6f89
Awaiting signature
Morgan Michels
Party ID: 1e52cc76-57d5-4454-a0d9-ec35313547d8
Awaiting signature
Jenna Meffert
Party ID: babcd67e-68bd-4ab1-a4a1-4d2f973d6e23
Awaiting signature
Kaylee Aebersold
Party ID: 9fd804b9-8a26-42a5-a271-7211ad0f170b
Awaiting signature
Chelsey Mcpheeters
Party ID: 9c237f39-cf0a-48ee-a38f-7362b38935c7
Awaiting signature
Kasey Gutgsell
Party ID: 61546be6-828f-4aeb-a3fe-298018c96b4e
Awaiting signature
Lainey Hayden
Party ID: bcb6b989-e7af-4a69-9b54-d067b84fa30b
Awaiting signature
Zach Callery
Party ID: 5c3530c0-babc-4de4-9f82-b1ae37280538
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Zoe Mclaughlin
Party ID: 90e58bc0-2129-492a-94da-63ee37dd2264
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Olivia Grass
Party ID: 7c8add3a-afae-4cc0-a90a-9f1a5ae77c81
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Phyllis White
Party ID: 306c1339-307c-45e3-bc01-3cbbe1b892a7
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Monika Douglas
Party ID: 721af955-2106-45a4-95b5-3fbd8441d98a
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Renee Eldridge
Party ID: becb2b5a-0513-4c45-a3d6-c5ab799d7582
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Courtney Zurkuhlen
Party ID: d1697c50-5262-43d1-b041-3dc5e7d3e93f
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Amber Zurkuhlen
Party ID: b54188b3-5843-4c29-9b45-9e5fd2fb151b
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Brandon Ray
Party ID: 7bcff532-f1b3-4bb0-b7d4-656b3e19ba2e
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Jill Miles
Party ID: 7094f52e-d40c-4d35-9a0e-55cad61644f8
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Luis Escobar
Party ID: 8e65593b-7bd2-4327-975f-df5a88c21a80
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Karleigh Rapson
Party ID: 5ac93189-ade9-4d80-8505-9d38126361db
Awaiting signature
Madison Reynolds
Party ID: cc3f4936-26fd-4296-859f-c7fbd889a066
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Ava Peters
Party ID: 1ff37cfd-4118-4aed-8fb8-569baeee74f8
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Andrea Sleep
Party ID: 9d136325-00e9-4830-8e22-afb770a9ea52
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Shireen Jameel
Party ID: 22a0ddab-f196-430d-95e7-7f1455632331
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Lisa Holland
Party ID: 1cdba1f3-fafa-4394-b08e-8ea238b52550
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Whitley Lehman
Party ID: 6636057f-c3be-42e0-abb5-a1f8cc292e9d
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Jonathon Bennett
Party ID: 2efd62f5-4d08-472d-a41b-dd463fa58e4f
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Carly Rizzo
Party ID: c4a69f8b-558a-4bc2-9641-dbd8af044b4f
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Mel’Vontae Reese
Party ID: 4abf854f-ecd2-4c80-acd0-c76457425345
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Angela Blevens
Party ID: 172c1cbd-0b1f-4805-a625-d16a29c33ff4
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Makenzie Barnes
Party ID: ae670515-207f-4134-afde-f6edfa1bfce3
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Libby Smith
Party ID: 84ac7660-e75d-4a7f-a986-6e8d38ce98bc
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Mckenzie Schnarr
Party ID: c32946fd-f071-4f57-a111-f1edcae30358
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Caroline Pender
Party ID: f15618fe-eb1f-4efa-8a7d-44dc21a01077
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Tye Lewis
Party ID: 4b83039b-04ce-4f5b-8db6-2575f2959d23
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Sabrina Naser
Party ID: aeb7b1f5-721c-4f79-97e6-73a81676a163
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Jordan DeJarnette
Party ID: d359e351-6398-4fea-8727-835aed2ee7bd
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Shelby Fuller
Party ID: 89f4af49-5fa6-4eb3-8192-9c4b60af6cd1
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Lauren Cahalan
Party ID: b5a47954-8ad8-4da7-9b18-7344ec580f2d
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Riley Hostutler
Party ID: d006157b-890d-493c-8d03-f019d6f6db98
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Luis Escobar
Party ID: 8699283e-de70-4081-a907-ae18d7fc4225
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Celia Kellicker
Party ID: a05b64bd-e64a-4bfc-8e32-d14ff989ab2e
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Allyson Rodriguez
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Edvin Habibovic
Party ID: 682ddac6-6b88-4fef-9b5e-3c8ac653b575
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Timestamp Audit
December 13, 2025 1:56 pm EDTDermal Fillers Informed Consent Uploaded by ENNU Patient Docs - ennu-appointments@ennu.co IP 139.68.242.135
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