Skin Treatment Consent Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Please select the suitable ones that describe your skin
Always
Moderately
Seldom
Rarely
Never
Not Applicable
Easily sun burn
Deep tans
Please give details about the products you use for your skin.
skincare, etc.
Are you currently taking any medical or dental treatment?
Yes
No
Please give details ( Don't forget to write the medications you use)
As far as you know do you have any allergies?
Yes
No
Please give details
Have you used any hormonal contraceptives lately?
Yes
No
Not applicable
Are you pregnant or breast feeding right now?
Yes
No
Not applicable
Please select if you suffer from any of the conditions listed below
Psoriasis
Eczema
Diabetes
Hay-fever
Sensitive skin
Epilepsy
Cold sores
Herpes
Blood borne diseases
Other
Did you have any laser treatments or chemical peels in the last two month?
Yes
No
Which one(s) do you want to solve with this treatment?
Allergy prone skin
Excessive hair
Dehydration
Wrinkles
Sensitivity
Thin lips
Breakouts
Dryness
Crows feet
Scarring
Post Acne
Sun damage
Open pores
Tightness
Aging
Hot flushes
Rosacea
Sunspots
Itchiness
Reduce elasticity
Capillaries
Flushing
Pigmentation
Spider veins
Fine lines
Coarse skin
Frown lines
Blackheads
Oiliness
Increased pore size
Other
I agree with the following statements
I have given enough information about the procedures, risks and side effects of the skin treatment that I am to undergo. I asked all of my questions to my health care provider and got the answers I need. By considering all aspects I decided to undergo the skin treatment of my own accord. I will not be able to sue my health care provider in case of complications or ask for return in the case of not satisfactory results.
I have informed about alternative treatments and I decided to take skin treatment on my own accord.
I will follow the after treatment advices given to me by my health care provider.
I had enough time to think, consider alternatives and ask questions about the treatment.
I understand every question asked above and answer them truthfully.
I AM GIVING MY CONSENT TO RECEIVE SKIN CARE TREATMENT BY MY SKIN CARE & WELLNESS PROVIDER.
Date
-
Month
-
Day
Year
Date
Signature
Submit
Submit
Should be Empty: