Skin Treatment Consent Form

Skin Treatment Consent Form
Name
First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please select the suitable ones that describe your skin
Rows Always Moderately Seldom Rarely Never Not Applicable
Easily sun burn
Deep tans
Please give details about the products you use for your skin.
skincare, etc.
Are you currently taking any medical or dental treatment?
Please give details ( Don't forget to write the medications you use)
As far as you know do you have any allergies?
Please give details
Have you used any hormonal contraceptives lately?
Are you pregnant or breast feeding right now?
Please select if you suffer from any of the conditions listed below
Other
Did you have any laser treatments or chemical peels in the last two month?
Which one(s) do you want to solve with this treatment?
Other
Purpose of the Consent:
This consent form is written to ensure there is an ongoing communication process between the client and the health care provider. It is important that the client fully understand the risks and complications of the treatment and asked any question before the treatment started.
Risks and Side Effects:
The possible side effects are listed below. However, the client should be aware that there may be unique effects to certain people that are not known right now.
- The skin might experience temporary irritation, tightness, redness, or slight swelling.
- The skin may experience temporary or permanent color change,
- Herpes infections may be reactivated if there is a prior history.
- The skin may experience a flare of acne-like lesions.
I agree with the following statements
I have given enough information about the procedures, risks and side effects of the skin treatment that I am to undergo. I asked all of my questions to my health care provider and got the answers I need. By considering all aspects I decided to undergo the skin treatment of my own accord. I will not be able to sue my health care provider in case of complications or ask for return in the case of not satisfactory results.
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Clear
Should be Empty:

Rows	Always	Moderately	Seldom	Rarely	Never	Not Applicable
Easily sun burn
Deep tans