General Consent Form
SECTION 1 — Client Details
Name (First / Last)
First Name
Last Name
Email
example@example.com
Phone Number
Format: 00000000000.
Address
Date of Birth
-
Day
-
Month
Year
Date
SECTION 2 — Medical Questionnaire
Please answer the following questions truthfully and to the best of your knowledge. This information helps us ensure your safety and customise your treatment plan.
1. Are you currently under the care of a physician? (Yes / No) - If yes, please describe
2. Do you have any medical conditions? (Yes / No) - If yes, please describe (diabetes, epilepsy, heart disease etc)
3. Are you pregnant, nursing, or planning to become pregnant? (Yes / No)
4. Do you have any allergies? (Yes / No) - If yes, please describe
5. Are you currently taking any medications? (Yes / No) - If yes, please describe (vitamins, herbal supplements)
6. Have you recently had any facial procedures? (Yes / No) - If yes, please describe (chemical peels, fillers, laser, etc)
7. Do you have a history of cold sores, keloid scarring, or skin sensitivities? (Yes / No) - If yes, please describe
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SECTION 3 — Acknowledgment and Consent
I understand that facial treatments are elective cosmetic procedures and not a substitute for medical treatment.
The purpose and nature of the treatment have been explained to me.
Possible side effects may include temporary redness, swelling, irritation, or sensitivity.
Results may vary depending on my skin condition and adherence to aftercare instructions.
No specific results can be guaranteed.
I will follow all pre- and post-treatment care instructions provided by my practitioner.
I must inform the practitioner of any changes in my health or medication prior to treatment.
I understand that certain treatments may have contraindications based on my medical history.
I have disclosed all relevant information to ensure my safety.
Client Declaration
I certify that I have read and fully understand the contents of this form. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction. I hereby give my voluntary consent to receive the selected treatments.
Client Signature:
Date:
-
Day
-
Month
Year
Date
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