Spa New Patient Consent Form

Patient Basic Information Form:

to be filled out by the patient seeking aesthetic services
Full Name*

First NameMiddle InitialLast Name
Gender*
Birth Date*

MonthDayYear
Date
Age*
Phone Number*
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact*
First and Last Name
Emergency Contact Phone Number*
Please enter a valid phone number.

How did you hear about Better Beauty & Wellness, LLC?*
Referral's Name (they will get $20 off their next service!)*
First and Last Name
Party Host's Name*
First and Last Name
Other*

Medical History

to be filled out by the patient
Are you under a doctor's care at the present time?*

YesNo
If yes, please explain:
Are you pregnant or breastfeeding?*

YesNo
Do you have allergies to any medications?*

YesNo
Medication*
Reaction*
Medication
Reaction
Medication
Reaction
Are you currently taking any medications?*

YesNo

Medical & Skin History: Do you currently or have you ever had any of the following?*

	Yes or No	Please explain/elaborate:
Herpes
Sensitivity to Anesthetic
Lupus
Photosensitive Disorder
Autoimmune Disease (RA, etc.)
Keloid Scars
Skin Cancer
Cold Sores
Skin Infections
Hypersensitivity to Skin Products
Use of Acne Products/Drugs
Laser Skin Resurfacing
Chemical Peels
Laser Work of Any Kind
Recent Increase in Amount of Hair
Asthma
Eczema
Thyroid Imbalance
Poor Healing
Diabetes
Heart Conditions
High Blood Pressure
Pacemaker
Disease of nerves or muscles? (ALS, etc.)
HIV/AIDS
Hepatitis
Shingles
Other:

Please answer the following?*

	Yes or No	Please explain/elaborate:
Do you form thick or raised scars from cuts or burns?
Do you buise or bleed easily?
After injury to the skin, do you have darkening or lightening of the skin?
Have you had hair removal by plucking, waxing, or electrolysis in the last 4 weeks?
Tanning (bed or sun) exposure in the last 4 weeks?
Tanning products or spray tan in the last 2 weeks?
Do you use sunscreen daily with SPF 30 or higher?
History of skin cancer or unusual moles?
Have you ever had a photosensitve disorder?
History of seizures?
History of migraines?
Do you have permanent makeup or tatoos? (if yes, please share where)
Have you used Accutane in the last 6 months?
Are you currently taking antibiotics?
Are you using Retin-A or glycolic acid products?
Do you currently smoke?
Allergy or sensitivity to lidocaine, latex, sulfa, aspirin, aloe, or bee stings?
Other?

I attest the medical history provided is true, knowing my provider relies on this information to provide safe and effective treatment.*

Clear
Date*

MonthDayYear
Date
What services are you interested in?*

Chemical Peels and/or Microdermabrasion and/or DermaplaningMicroneedlingPRP (Platelet-Rich Plasma)
What areas and/or concerns are you interested in treating?

Informed Consent for Spa Services

Spa treatments include, but are not limited to, microdermabrasion, dermaplaning, chemical peels, and the use of topical skin care products.
This consent form provides the necessary information to assist patients in making an informed decision regarding receiving skin care/spa treatments that include, but are not limited to, microdermabrasion, dermaplaning, chemical peels, and the use of topical skin care products.

Microdermabrasion is a mechanical method of removing the outermost layers of the skin using abrasive elements such as a diamond-dipped pad. Dermaplaning exfoliates the skin and removes dirt and vellus hair using a scalpel. Chemical peels remove the top layers of the skin using acids such as glycolic, lactic, salicylic, and trichloroacetic acid.
Alternative treatments to microdermabrasion, dermaplaning, and chemical peels include laser skin resurfacing, dermabrasion, plastic surgery, or no treatment at all.

Possible risks, side effects, and complications with Spa Services include, but are not limited to:
Prolonged erythema (redness) or edema (swelling)
Allergic reactions
Blistering
Visible flaking/peeling
Hyperpigmentation or hypopigmentation
Abrasion (superficial cut) or temporary lines and streaks may occur
Acne outbreak or the activation of recurrent viral infections such as herpes simplex may occur
Infection or scarring

The risks of complications are higher for patients with darker skin types. I have disclosed any condition that may have bearing on this procedure such as: pregnancy, recent facial surgery, allergies, tendency to cold sores/fever blisters, or use of topical and/or oral prescription medications.

I understand that it is not possible to predict any of the above side effects or complications, and results are not guaranteed. I have fully read this consent form and understand the information provided to me regarding the proposed procedures, and I have had all questions and concerns answered to my satisfaction.

THIS CONSENT FORM IS VALID UNTIL ALL OR PART IS REVOKED BY ME IN WRITING.
Signature*

Clear
Date*

MonthDayYear
Date

Informed Consent for Microneedling
This consent form provides the necessary information to assist patients in making an informed decision regarding receiving microneedling treatment and will go over expectations, side effects, and more.

I understand that I will be undergoing a microneedling treatment with Kelli DiMattia, FNP in the facial area. The procedure uses fine gauge needles to create micro-channels on the treated area.

Microneedling is ‘Class I’ FDA-approved supplemental medical device that treats various skin conditions such as aging (wrinkles, stretching), scarring (acne, surgical), and hyperpigmentation. I understand that multiple treatments are necessary to achieve desired results. Lasting and more significant results will start occurring after 2 to 3 treatments (spaced 2-4 weeks apart) when combined with the recommended post-treatment care. Touch up treatments may be necessary to maintain desired results. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. Results will vary by patient. I agree to adhere to all safety precautions and regulations during and after the treatment. No refunds will be given for treatments received.

Possible side effects of microneedling can include but are not limited to: Allergic reaction or infection, bleeding, tenderness or pain, redness, bruising, scarring, lumps, bumps or swelling.

I have disclosed any condition that may have bearing on this procedure such as: allergy to metal or lidocaine, asthma, hay fever, eczema, a history of multiple allergies, or if I am pregnant, nursing, or trying to become pregnant.

I understand that it is not possible to predict any of the above side effects or complications, and results are not guaranteed.

This consent form is freely and voluntarily executed. I certify that I am a competent adult of at least 18 years of age. I have fully read this consent form and understand the information provided to me regarding the proposed procedures. I have had all questions and concerns answered to my satisfaction. I release Kelli DiMattia, FNP, Better Beauty and Wellness, LLC, their staff, and technicians from liability associated with the procedure. I hereby authorize Kelli DiMattia, FNP to perform the agreed upon procedure involving the microneedling device and targeted treatment solutions.

THIS CONCENT FORM IS VALID UNTIL ALL OR PART IS REVOKED BY ME IN WRITING.
Signature*

Clear
Date*

MonthDayYear
Date

Informed Consent for Platelet-Rich Plasma Treatment

also known as PRP
This consent form provides the necessary information to assist patients in making an informed decision regarding receiving platelet rich plasma treatment and will go over expectations, side effects, and more.

Platelet Rich Plasma, also known as "PRP" is an injection where your own blood is used. Approximately 10- 20 cc (2 Tablespoons) of blood is drawn up into a syringe. The blood is spun in a special centrifuge to separate its components (Red Blood Cells, Platelet Rich Plasma, Platelet Poor Plasma and Buffy Coat). When PRP is injected into the damaged area it causes a mild inflammation that triggers the healing cascade. As the platelets organize in the treatment area they release several enzymes to promote healing and tissue responses including attracting stem cells and growth factors to repair the damaged area. As a result, new collagen begins to develop. As the collagen matures it begins to shrink causing the tightening and strengthening of the damaged area. When treating injured or sun and time damaged tissue, they can induce a remodeling of the tissue to a healthier and younger state. The full procedure takes approximately 45 minutes to an hour. Generally, 2-3 treatments are advised, however, more may be necessary for some individuals.

BENEFITS of PRP: Along with the benefit of using your own tissue therefore eliminating allergies, there is the added intrigue of mobilizing your own stem cells for your benefit. Other benefits include minimal down time, safe with minimal risk, short recovery time, natural looking results; no general anesthesia is required.

CONTRAINDICATIONS: PRP used for aesthetic procedures is safe for most individuals between the ages of 18-80. There are very few contraindications, however, patients with the following conditions are not great candidates: 1) Acute and Chronic Infections 2) Skin diseases (i.e. SLE, porphyria, allergies) 3) Chronic Liver Pathology 4) Patients that need to be aspirin, and Systemic use of corticosteroids within two weeks of the procedure.

RISKS & COMPLICATIONS: Some of the Potential Side Effects of Platelet Rich Plasma include: 1) Pain at the injection site; 2) Bleeding, Bruising and/or Infection as with any type of injection; 3) Short lasting pinkness/redness (flushing) of the skin; 4) Itching at the injection site(s); 5) Swelling; 6) The treatment not working on you

RESULTS: PRP has been shown to have overall rejuvenating effects on the skin including improving skin texture, thickness, fine lines and wrinkles, increasing volume via the increased production of collagen and Elastin, and by diminishing and improving the appearance of scars. Results are generally visible at 4 weeks and continue to improve gradually over ensuing months (3-6) with improvement in texture and tone. Advanced wrinkling cannot be reversed, and only a minimal improvement is predictable in persons with drug, alcohol, and tobacco usage. Severe scarring may not respond. Touch up treatments may be done once a year to boost and maintain the results.

This consent form is freely and voluntarily executed. I certify that I am a competent adult of at least 18 years of age. I have fully read this consent form and understand the information provided to me. I have had all questions and concerns answered to my satisfaction. I agree to adhere to all safety precautions and instructions after the treatment. I understand that there is no guarantee as to the results that may be obtained. I release Kelli DiMattia, FNP, Better Beauty and Wellness, LLC, their staff, and technicians from liability associated with the procedure. I hereby authorize Kelli DiMattia, FNP to perform the agreed upon elective platelet rich plasma procedure.
Signature*

Clear
Date*

MonthDayYear
Date

Financial Policy

Thank you for selecting Better Beauty and Wellness, LLC for your health care. We are honored to be of service to you and your family. This is to inform you of your billing requirements and our financial policy. Please be advised that payment for all services will be due at the time services are rendered. For your convenience we accept Visa, Mastercard, Discover, American Express, Venmo, HSA/FSA cards, and CareCredit.
I have read and understand the above and agree to the financial policy:*

Clear
Date*

MonthDayYear
Date
HIPAA Privacy Notice

I understand that Better Beauty & Wellness, LLC follows The HIPAA Privacy Rule which requires appropriate safeguards to protect the privacy of protected health information and sets limits and conditions on the uses and disclosures that may be made of such information without your authorization. The Rule also gives you rights over your protected health information, including rights to examine and obtain a copy of your health records, request corrections, or request it be sent to another party.
I have read and understand the HIPAA Privacy Notice:*

Clear
Date*

MonthDayYear
Date

Can't wait to see you!

If you have questions, you can contact me using the information below -- otherwise go on and hit submit!
Should be Empty:

	Name of Medication	Prescription or Over-the-Counter?	Dosage	Schedule
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6

Patient Basic Information Form:

Medical History

Informed Consent for Spa Services

Informed Consent for Microneedling

Informed Consent for Platelet-Rich Plasma Treatment

Can't wait to see you!