Registro de Nuevo Paciente

Registro de Nuevo Paciente

Completa este formulario para darte de alta como paciente en nuestra clínica estética.
Nombre completo

NombreApellido
Fecha de nacimiento

MesDíaAño
Fecha
Correo electrónico
ejemplo@ejemplo.com
Teléfono
Favor ingrese un número de teléfono válido.Format: (000) 000-0000.
Dirección

Dirección de la calle

Dirección de la calle Línea 2
CiudadEstado / ProvinciaCódigo Postal / Zip
3. INFORMED CONSENT FOR AESTHETIC PROCEDURES

I voluntarily consent to receive aesthetic skin care treatments provided by Cryscha Aesthetic Skin Clinic. Risks: I understand possible temporary side effects include: Redness, Swelling, Peeling, Dryness, Bruising, Sensitivity, Hyperpigmentation, Hypopigmentation, Allergic Reaction, Infection (rare), Unsatisfactory Results. Acknowledgment: I understand: Results vary from person to person. Multiple sessions may be required. Following home-care instructions is essential. No guarantees have been made regarding the results. I have disclosed all relevant medical conditions. I may stop treatment at any time. I have had the opportunity to ask questions.
I voluntarily consent to receive aesthetic skin care treatments provided by Cryscha Aesthetic Skin Clinic.
Consent
I voluntarily consent to receive treatment.
Client Name

First NameLast Name
Date

MonthDayYear
Date
Signature
Historial médico

Marca las opciones que apliquen a tu estado de salud.
Indica tu historial médico relevante

Otra condición
Do you have sensitive skin?
Have you had allergic reactions to skincare products?
Current medications
If yes, explain
If yes, list them
2. PHOTO & VIDEO CONSENT FORM

Photography & Video Consent
Cryscha Aesthetic Skin Clinic
I authorize Cryscha Aesthetic Skin Clinic to take photographs and/or videos before, during, and after my treatments.
I understand these images may be used for:
I understand:
My identity will remain confidential whenever possible. I will not receive financial compensation. I may revoke this authorization in writing before publication.
Choose One
Client Name

First NameLast Name
Signature
Date

MonthDayYear
Date
Should be Empty:

Registro de Nuevo Paciente

3. INFORMED CONSENT FOR AESTHETIC PROCEDURES

Historial médico

2. PHOTO & VIDEO CONSENT FORM