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Skin Treatment Consent Form

Please fill out the following form.

Date of birth
Day
Month
Year

Patient Medical History

Currently Pregnant or Breastfeeding
YES
NO
Known Allergies (Medications, Latex, Antiseptics)
YES
NO
Autoimmune Disease
YES
NO
Seizures
YES
NO
Diabetes
YES
NO
Migraines
YES
NO
Blood Disorders / Clotting Issues
YES
NO
Heart Conditions
YES
NO
High Blood Pressure
YES
NO
Epilepsy
YES
NO
Current Infection or Illness
YES
NO
Asthma
YES
NO
Skin Conditions (Eczema, Psoriasis, Dermatitis)
YES
NO
Are you currently receiving any Medical treatment?
YES
NO
Please select the treatment you are coming in for

Skin-Specific History

Sensitive or Reactive to Skin
YES
NO
Active Acne or Infection
YES
NO
Use of Retinoids (Last 7-14 Days)
YES
NO
History of Eczema or Rosacea
YES
NO
Poor Wound Healing
YES
NO

Peel / Microneedling Disclaimer

I understand i may have temporary Redness, Peeling, Dryness may occur
YES
NO
I understand the risk of Pigmentation if aftercare is not followed
YES
NO

Consent Declaration

I Confirm the Information provided is accurate
YES
NO
I Consent to Images/Videos being taken for Medical Records
YES
NO
I Consent to Anonymized Marketing use of Images / Videos
YES
NO
I Consent to Treatment following Consultation
YES
NO

The clinic shall not be held liable for treatment outcomes or perceived treatment failure where procedures have been carried out appropriately and in accordance with accepted professional practice and aftercare guidance.

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