Microdermabrasion Consent Form

Obtains the patient's signed authorization before a microdermabrasion treatment, along with personal details and any contraindications. It also asks for photo permission and records a witness signature.

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In the Claude connectors directory

Today's date

Patient name

First Name

Last Name

Age

Gender

Female Male Other Prefer not to say

Date of birth

Email

Phone number

Address

Street Address

City

State / Province

ZIP / Postal Code

Occupation

Contraindications

Do you have any of the contraindications listed above?

Yes No

Photo consent: may the clinic photograph your face for marketing use (banners, website and social media)?

Yes, I allow it No, I decline

Consent statement

Patient signature

Sign here

Date signed

Witness name

First Name

Last Name

Witness signature

Sign here

Date signed

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