AUTHORIZATION TO DISCLOSE HEALTH INFORMATION

Use this form to request an itemized copy of your healthcare records with Mirza Aesthetics. Unless otherwise indicated, only the most recent records will be included. 

, Client Portal, Mirza Aesthetics
, Client Portal, Mirza Aesthetics

ALLē

If you were unable to note your membership during your visit to the office, you may use this form. Points can only be issued retroactively up to 2 months. Allē, formerly Brilliant Distinctions, is managed by Allergan Aesthetics.

CONSENT TO TREAT

By signing this form, you consent to treatment by Mirza Aesthetics; and acknowledge that because every individual is different, results from aesthetic services cannot be guaranteed.

, Client Portal, Mirza Aesthetics
, Client Portal, Mirza Aesthetics

OTHER QUESTIONS OR CONCERns

Use this form to submit any other questions you may have regarding your treatment. Please allow up to 3 business days for a response.