Treatment Consent Form

Treatment Consent Form
Name*

First NameLast Name
Date of Birth *

DayMonthYear
Date
Address*

Address Line 1

Address Line 2

Town/VillageCounty

Post Code
Phone Number*
Email*
example@example.com
Emergency Contact
Emergency Contact Telephone Number
Your Medical History
Are you currently under the care of a physician?*

YESNO
Have you experiences any of these health conditions in the past or present?*

Cancer/ Systemic diseaseHigh Blood PressureDiabetesHeart ConditionsStrokeArthritisHepatitisKidney DisorderLiver DisorderDigestive ProblemsMigraineAuto-immune DisorderAsthmaEpilepsy/SeizuresCold sores/blistersLupusDepression/AnxietyHeadaches/ MigrainesEczemaPsoriasisDermatitisHistory of AnaphylaxisDiabetesHaemophiliaBlood DisordersRecent Virus (within the last 2-4 weeks)History of Skin CancerAre you Pregnant or Nursing/ Receiving Fertility TreatmentHormonal Imbalance (PCOS/Endometerosis/Fibroids/Cysts)Taken Acctutane in the last 6 monthsGlucomaChest Pain/Shortness of BreathAllergiesHistory of Keloid ScarringLong CovidNONEOther
Are you taking prescribed medication including the Contaceptive Pill/ HRT – State brand
Are you taking any non prescription medication including Vitamin supplements, St Johns Wort, Probiotics etc?
Do you have any allergies?*

AsprinLatexFruitsShellfishLidocaineFragrance/Essential OilsNutsDairySunscreenPollenOther
Your Treatment and Product History
Have you had any of the following skin care treatments in the last 3 months?

Chemical PeelMicrodermabrasion/ HydrafacialBotoxFacial FillerLaserElectrolysisHair RemovalMicroneedlingSurgeryPDO Thread LiftOther
If you ticked any of the above when did you last have the treatment?
Do you use any of the following?

RetinolHydrocortisoneTretinoinHydroquinone
The use of Retinol, Hydrocortisone, Tretinoin or Hydroquinone may be a contraindication to facial treatments and potentially cause adverse side effects
Have you had any form of Semi Permanent Makeup, If so when was your last treatment?
What skin care products do you currently use?

CleanserMoisturiserTonerAntioxidant SerumEye CreamSpot TreatmentSunscreenVitamin C SerumFace OilOther
Appointments and Cancellations

I acknowledge that I must adhere to Charlotte Rye Aesthetics policies.

I understand that cancellations must be made with at least 48 hours notice.

I acknowledge that ANY No-Show will result in the loss of a single treatment from a pre paid course or 100% of the total service cost.

I understand that if I arrive late for my appointment it may be subject to cancellation or to a reduced treatment time and I will be responsible in accordance with the “No-Show” policy.
Consent & Agreement
I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment.

I declare that I have been made aware of and understand the information provided to me about the treatment.

The use, indications, contraindications, and potential adverse effects of the treatment have been explained to me.

The benefits of what I can realistically expect to see from the treatment have been fully explained and can not be guaranteed.

I agree to follow the home care advice given and understand that not doing so may affect the outcome of the treatment.

I give my permission to Charlotte Rye, without any reservations, to carry out the treatment.

I release Charlotte Rye of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.
Date*

DayMonthYear
Date
Signature*

Clear
Treatment Notes
Should be Empty:

Treatment Consent Form

Your Medical History

Your Treatment and Product History

Appointments and Cancellations

Consent & Agreement