• Aesthetic Treatment Medical History & Consent

    Complete your medical and safety screening details for a non-surgical aesthetic consultation, then acknowledge consent before clinician review.

  • Patient Details

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Treatment Request

  • Treatment(s) of Interest*
  • Areas of Concern*
  • Previous Aesthetic Treatments

  • Medical History

  • Current medical conditions
  • Past medical conditions
  • Allergies or sensitivities
  • Bleeding or clotting problems
  • Skin conditions or infections
  • History of keloid or raised scarring
  • Previous adverse reactions

  • Safety Screening

  • Are you pregnant, breastfeeding, or trying to conceive?*
  • Have you had any recent illness or infection?*
  • Have you had any recent dental work or other procedures relevant to the treatment?
  • Do you currently have any skin irritation, wounds, or an active infection in the treatment area?*
  • Do you take any anticoagulants or medicines that may affect healing?*
  • Previous cosmetic treatments and product details

  • Skin and Treatment Assessment

  • Skin type*
  • Main skin concerns*
  • Current skincare products used
  • Sun exposure and tanning habits*
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  • Consent and Acknowledgements

  • Acknowledgements and Consents*
  • Consent Notice
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: