General Treatment Consent Form
Client Name:
Date of Birth:
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Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Address:
Phone Number
Please enter a valid phone number.
Format: 00000000000.
Email
example@example.com
Treatment(s) Requested:
Date:
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Medical History
Please complete the following accurately. This information helps ensure your safety.
Medical Conditions
List any current or past medical conditions (e.g., heart disease, diabetes, autoimmune disorders, epilepsy, bleeding disorders, skin conditions, mental health conditions):
Medications
List all medications you are currently taking, including prescription, over-the-counter, herbal supplements, and vitamins (e.g., blood thinners, steroids, acne medication, antihistamines):
Allergies
List any known allergies, including medication, latex, anaesthetics, skincare products, or food allergies:
Back
Next
Previous Aesthetic Treatments
Have you had any aesthetic treatments before? (e.g., fillers, Botox, chemical peels, laser treatments) If yes, please specify:
Yes
No
Other
Consent and Acknowledgement
Please read and initial each statement:
I confirm that the information I have provided is accurate and complete to the best of my knowledge.
I understand the nature of the aesthetic treatment(s) I am receiving, including the expected benefits, possible risks, and potential side effects.
I understand that results vary between individuals and that no specific outcome can be guaranteed.
I understand that aesthetic treatments may involve temporary discomfort, bruising, swelling, redness, or other side effects.
I understand that I must follow all aftercare instructions provided to me.
I confirm that I am not under the influence of drugs or alcohol at the time of signing this consent.
I understand that photographs may be taken for medical documentation and treatment planning. (You may opt out: I do NOT consent to photographs.)
I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction.
Client Declaration
I confirm that I have read and understood this consent form. I voluntarily agree to undergo the aesthetic treatment(s) listed above.
Client Signature:
Date:
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
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