(571) 379-04428609 Sudley Rd, Suite 204 · Manassas, VA 20110
Revive ValleySkin · Metabolic · Gut

Patient forms

One form per treatment, ready to download.

Our consent packet is split into separate PDFs so you only print what your appointment needs. Tap any cover image to download that form, read it at your own pace, and bring the signed pages with you.

Every patient

Start here — these two apply to every appointment we schedule.

First page preview of the Pre & post-treatment instructions

Pre & post-treatment instructions

What to do in the days before your appointment and how to care for your skin afterwards. Read this first, whatever you are booking.

PDF · 112 KB

General consent, privacy & financial policy

New-patient consent to evaluate and treat, HIPAA privacy acknowledgement, photography permission and the cancellation policy.

PDF · 46 KB

Injectables

Neurotoxin, filler and thread lifting consents.

First page preview of the Neurotoxin consent — Botox®, Dysport®, Xeomin®

Neurotoxin consent — Botox®, Dysport®, Xeomin®

Wrinkle-relaxing injections, lip flip and masseter treatment: how neuromodulators work, onset and duration, risks and aftercare.

PDF · 123 KB
First page preview of the Dermal & lip filler consent

Dermal & lip filler consent

Hyaluronic acid filler for lips, cheeks, chin and jawline, including medical history, vascular risk and post-treatment expectations.

PDF · 136 KB
First page preview of the Silhouette InstaLift® consent

Silhouette InstaLift® consent

Absorbable suspension-suture lifting: candidacy, before and after instructions, and the risks associated with thread placement.

PDF · 122 KB

Skin treatments

Microneedling, plasma, peels, HydraFacial and laser consents.

First page preview of the Microneedling consent

Microneedling consent

Collagen induction therapy with a micro-pen: expected downtime, pigment considerations and aftercare requirements.

PDF · 118 KB
First page preview of the Microneedling with radiofrequency consent

Microneedling with radiofrequency consent

RF microchanneling for skin tightening — energy settings, contraindications, healing timeline and post-care.

PDF · 118 KB
First page preview of the Plasma Pen IQ consent

Plasma Pen IQ consent

Plasma fibroblast skin tightening: eligibility screening, cardiac and pigment contraindications, and strict aftercare rules.

PDF · 150 KB
First page preview of the HydraFacial® consent

HydraFacial® consent

Cleansing, exfoliation, extraction and hydration treatment with client acknowledgements and skin sensitivity disclosures.

PDF · 117 KB
First page preview of the VI Peel® consent

VI Peel® consent

Medium-depth chemical peel: peel type and lot documentation, sun and sweat restrictions, and expected peeling timeline.

PDF · 134 KB
First page preview of the Chemical peel consent — Glytone, Vitalize, Rejuvenize

Chemical peel consent — Glytone, Vitalize, Rejuvenize

Superficial to medium chemical peels: potential risks, complications, and post-peel skin care instructions.

PDF · 125 KB
First page preview of the Laser hair reduction & removal consent

Laser hair reduction & removal consent

Laser hair reduction: medical history screening, realistic expectations across multiple sessions and required follow-up.

PDF · 139 KB

Hair restoration

PRP for thinning hair.

First page preview of the PRP hair restoration consent

PRP hair restoration consent

Platelet-rich plasma for thinning hair: blood draw authorization, treatment series expectations and maintenance schedule.

PDF · 120 KB

Medical weight management

GLP-1 therapy consent and program terms.

GLP-1 medical weight management consent

Semaglutide and tirzepatide therapy: titration, monitoring, side effects, thyroid and pregnancy warnings and program terms.

PDF · 46 KB

Service consent forms are the practice's own documents. The general consent, privacy and financial policy and the GLP-1 weight management consent are drafts prepared for this site and should be reviewed by the clinic's medical director before clinical use. Signing a form does not create a treatment plan — your provider reviews every risk, alternative and expectation with you in person first.

Pre & post-treatment care

What to do the week before — and the days after.

Before your appointment

  • Avoid alcohol for 24 hours and, if medically safe, non-essential blood thinners, fish oil and NSAIDs for 3–5 days before injectables
  • Reschedule if you have an active cold sore, skin infection, illness or recent vaccination
  • Arrive with clean skin and no makeup for injectable, microneedling or peel appointments
  • Eat a normal meal and hydrate well — especially before PRP, which requires a blood draw
  • For KORR metabolic testing: fast 4 hours, no caffeine or exercise beforehand

After your treatment

  • Stay upright for 4 hours after neurotoxin and avoid rubbing or massaging the area
  • No strenuous exercise, saunas, hot yoga or facials for 24–48 hours
  • Expect swelling and possible bruising for up to 7–10 days with filler; ice gently
  • After microneedling, plasma or a peel: gentle cleanser only, no actives for 5 days, daily SPF 30+
  • Call the clinic promptly for severe pain, blanching, vision change or signs of infection

Forms done? Let's get you on the schedule.

Booking takes a minute, and you can bring your completed paperwork to the visit.