Beauty Forte Aesthetics – Injectable Treatments Consent Form

Beauty Forte Aesthetics – Injectable Treatments Consent Form

Consent and information form for injectable aesthetic treatments at Beauty Forte Aesthetics.
Client Personal Details
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number, start without the 0.Format: (000) 000-0000.
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name*
Emergency Contact Phone Number*
Please enter a valid phone number, start without the 0.Format: (000) 000-0000.
Medical History Screening
Are you currently pregnant?*

YesNo
Are you currently breastfeeding?*

YesNo
Do you have any allergies?*

YesNo
Do you have any autoimmune diseases?*

YesNo
Do you have any bleeding disorders?*

YesNo
Are you currently taking any medications?*

YesNo
Are you taking blood thinners?*

YesNo
Have you had previous aesthetic treatments?*

YesNo
Do you currently have any skin infections or conditions?*

YesNo
Do you have a history of keloid scarring?*

YesNo
Do you have any neurological disorders?*

YesNo
Do you have any chronic illnesses?*

YesNo
Treatment Selection
Which treatments are you consenting to receive?*

BotoxDermal FillersLipolysis (Fat Dissolving) InjectionsThread LiftIV Therapy
About the Treatments
Botox: Botulinum toxin injections temporarily relax facial muscles to reduce the appearance of fine lines and wrinkles.

Dermal Fillers: Injectable gels used to restore volume, enhance facial contours, and reduce wrinkles.

Lipolysis (Fat Dissolving) Injections: Injections that break down and eliminate localized fat deposits.

Thread Lift: A minimally invasive procedure using dissolvable threads to lift and tighten sagging skin.

IV Therapy: Intravenous delivery of fluids, vitamins, and nutrients for wellness and rejuvenation.
Risks and Possible Side Effects
Possible side effects include swelling, bruising, redness, infection, asymmetry, allergic reactions, vascular occlusion (for fillers), temporary numbness, and the need for additional treatments.
Expected Results
Results may vary between individuals. Multiple sessions may be required to achieve optimal results. Outcomes cannot be guaranteed.
Photography Consent
I consent to photographs being taken for medical records and non-identifiable promotional use.*

Yes, I consent
Aftercare Acknowledgement
I acknowledge that I have received and will follow all aftercare instructions provided by Beauty Forte Aesthetics.*

I acknowledge and agree
Liability Waiver
By signing below, I release Beauty Forte Aesthetics and its practitioners from any liability related to my individual response to the selected treatments, understanding that results and risks may vary.
Final Client Declaration
I confirm that the information provided is accurate to the best of my knowledge and that I am giving my consent to proceed with the selected treatments voluntarily.*

I confirm and consent voluntarily
Client Signature*
Practitioner Signature*
Date*

MonthDayYear
Date
Should be Empty:

Beauty Forte Aesthetics – Injectable Treatments Consent Form

Client Personal Details

Medical History Screening

Treatment Selection

About the Treatments

Risks and Possible Side Effects

Expected Results

Photography Consent

Aftercare Acknowledgement

Liability Waiver

Final Client Declaration