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Aesthetic Treatment Consent Form

An informed consent form medical organizations use to record a patient's health background and obtain authorization before an aesthetic treatment.

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Name

First Name

Last Name

Age

I have read and understood the information above, and I give my consent to receive the described aesthetic treatment.

Signature

Sign here

Date Signed

The aesthetic therapist confirms having explained the risks, benefits, and alternatives of the treatment to the client.

Signature

Sign here

Date Signed

Client Reference Number

Aesthetic Therapist Name

First Name

Last Name

Address

Street Address

City

State / Province

ZIP / Postal Code

Date of Birth

Gender

Phone Number

Reason for Treatment

Are you Pregnant or Breastfeeding?

Yes No

Do you Suffer from Needle Phobia?

Yes No

Do you Have a History or Tendency to Faint?

Yes No

Do you Have a Tendency for Keloids or Excessive Scarring?

Yes No

Have you Had any Surgical Procedure in the Past 6 Weeks?

Yes No

Have you Ever Tested Positive for HIV or Hepatitis B/C?

Yes No

Have you Been Diagnosed with any of the Following? Angina, Diabetes, Epilepsy, Hepatitis A, Rheumatism

Angina Diabetes Epilepsy Hepatitis A Rheumatism None

Have you Ever Been Diagnosed with Multiple Sclerosis (MS), Myasthenia Gravis, or Another Neurological Condition?

Yes No

Have you Ever Been Diagnosed with any Severe Mental Health Condition?

Yes No

Have you Had an Abnormal Reaction to a Similar Procedure Before?

Yes No

Do you Tend to Develop Cold Sores, or Had One in the Past 2 Weeks?

Yes No

Do you Have a History of Anaphylaxis (Severe Allergic Reaction)?

Yes No

Do you Have a History of Allergy to any Medicines, Food, or Drink?

Yes No

Have you Ever Had an Abnormal Reaction to Local Anaesthetic (Injection/Cream)?

Yes No

Signature

Sign here

Date Signed

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