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Let's Get Down to Business

Please complete the following information accurately. This form must be filled out prior to receiving any service at Blush and Bows. Your safety and satisfaction are our top priorities. All information is kept confidential. Please review the Notice of Privacy Practices at the bottom of the page.

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Please take a moment to fill out the form.

Please check any and all that apply Required
Are you currently taking blood thinners (e.g., Bayer/aspirin, ibuprofen/Motrin, warfarin/Coumadin, fish oil, vitamin E, etc.)? Required
Do you have any of the Following Conditions? (Make at least one selection. May select multiple if applies) Required
Do you have any known allergies (especially to lidocaine, epinephrine, botulinum toxin, hyaluronic acid, nickel, latex, and/or shellfish)? Required
📄 INFORMED CONSENT FOR INJECTABLE SERVICES: I understand and acknowledge the following: ​ I am voluntarily receiving injectable aesthetic treatments (e.g., neurotoxins/neuromodulators like Botox® and/or dermal fillers). These treatments carry potential side effects, including but not limited to: redness, swelling, bruising, asymmetry, lumps, allergic reactions, infection, headache, muscle weakness, flu-like symptoms, or in very rare cases, vascular occlusion or tissue necrosis. Results may vary, and I understand no guarantees are made regarding outcome or duration. I agree to follow all pre- and post-treatment instructions provided by the injector. I release Christina Johnston, RN, Blush and Bows, and the medical director from liability for complications arising from undisclosed medical conditions or failure to follow post-treatment instructions Required
🔐 HIPAA PRIVACY POLICY NOTICE & CONSENT: Your health and personal information is protected under the Health Insurance Portability and Accountability Act (HIPAA). Your information will only be used for treatment, payment, and operational purposes and will not be disclosed to third parties without your written permission, unless required by law. Required
​​📸 PHOTO/VIDEO RELEASE AUTHORIZATION Blush and Bows may take before and after photos/videos for medical documentation, training, and marketing purposes. Please check one: Required

​✍️ CLIENT SIGNATURE:

By signing below, I confirm the following: I have answered this form honestly and to the best of my knowledge. I understand the nature of the procedures and consent to receive injectable treatment from Christina Johnston, RN at Blush and Bows. I have read and understand the risks, HIPAA notice, and photo release terms above.

Please upload any supporting file as needed to support any answers as above. *Not a Required Section.​

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📄 Blush + Bows – Notice of Privacy Practices (HIPAA Compliance)


Contact: Christina Johnston, RN | Phone: 505-585-5516 | Email: blushandbowsNM@gmail.com

This notice describes how medical information about you may be used and disclosed, and how you can access this information. Please review it carefully.

💬 Our Commitment to Your Privacy

At Blush + Bows, we are committed to protecting your personal and health information. This notice applies to all information we collect during your treatment, including forms, photos, and treatment history. We follow federal HIPAA (Health Insurance Portability and Accountability Act) guidelines to keep your data safe and confidential.

🔐 How We May Use and Share Your Information

We may use your health information:

  • To provide treatment and coordinate your care

  • To communicate with you about appointments and follow-ups

  • To run our business operations (quality improvement, staff training, audits, etc.)

  • When required by law (e.g., for public health, legal matters, or law enforcement)

We will not share your information for marketing or other purposes without your explicit written permission.

📸 Photo Release (Optional)

We may request your consent to use treatment-related photos on our website or social media platforms. Photos will only be used with your written authorization and can be withdrawn at any time. Please see above Form and make your selection. 

🔎 Your Rights Regarding Your Health Information

You have the right to:

  • Request a copy of your records

  • Request corrections to your records

  • Ask us to limit what we share

  • Request confidential communication (email, phone, etc.)

  • File a complaint if you believe your rights have been violated

To exercise these rights, please contact Christina, RN at 505-585-5516 or the U.S. Department of Health and Human Services (HHS).

⛔ What We Don’t Do

  • We do not sell your data.

  • We do not share your data with third parties for non-medical purposes without permission.

  • We do not disclose protected information unless required by law or consented by you.

📣 Questions or Complaints?

If you have any concerns about how your information is used, you may:

  • Call or text 505-585-5516

  • File a complaint directly with the U.S. Department of Health and Human Services (HHS) — we will never retaliate.

📝 Acknowledgement of Receipt

By signing in the above form, you acknowledge that you have received, reviewed, and understand this Notice of Privacy Practices. You can request a copy at any time.

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