New Client Intake/Consent Form

Consent Form
Name

First NameLast Name
Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Gender
Email Address
example@example.com
Phone Number
Medical Health Data

Please answer the following:

	Yes/No
Have you been treated for any dermal issues before?
Have you been treated with fillers or injectables before?
Have you ever been hospitalized? If yes, please indicate why and when in the Remarks section below.
Did you undergo any previous surgery? If yes, please indicate the procedure name, reason, and the date below.
Do you have any known allergies? If yes, then please specify in the Remarks section below.
Are you currently taking medications? If yes, then please list the medications and the reasons why are you taking them below.
What is your current medical condition? Do you have any communicable disease, cardiovascular problems, diabetes, asthma, etc.? If so, please indicate which ones below.
Are you pregnant, breastfeed, or nursing? (Female) Please indicate below.
Is there anything you would like to add? Please add it in the Remarks section below:

Remarks section:
Emergency Contact Details
Contact Name

First NameLast Name
Primary Phone Number
Secondary Phone Number
Acknowledgment, Authorization and Release
Please select "Yes" or "No" if you authorize Refresh Med Spa to perform procedure(s) listed below:
- Injectables
- Dermal Fillers
- Laser Treatments
- Microneedling
- Facials
- Chemical Peels
- Brow Lamination
- Full set lashes or lash fills
- Kybella
- Waxing
- PRP
- Occasion makeup
- Dermaplaning
- Red/Blue light therapy
- B12 injections
- IV hydration
- Semaglutide weight loss
Please read very carefully:
- I understand the advantages and disadvantages of these procedures. The esthetician/nurse practitioner explained the process thoroughly to me and addressed all of my questions.
- I allow this clinic to administer any necessary medications or reversal agents and understand the effects of the medications given to me.
- I understand the side effects that I may experience after the procedure.
- I allow Refresh Med Spa to take my photos and utilize these images for the company's portfolio or advertising.
- I release this clinic for any responsibility in case of an accident, illness, or injury.
- I understand the risk and complications if I do not follow the instructions given to me after the procedure which involves post-treatment and follow-ups.
- I acknowledge that no assurance was offered about the outcome.
- I acknowledge that all information I provided in this form is true and accurate.
Do you agree with the statements stated above?
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Date Signed

MonthDayYear
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Consent Form

Medical Health Data

Emergency Contact Details

Acknowledgment, Authorization and Release