top of page
Prime health
Prime health
Prime health
Celebrity Cosmetic Dermatologist
Home
Medical
Beauty
After Care
Skin Tightness
Location
Blog
Product
More
Use tab to navigate through the menu items.
AESTHETIC CONSENT FORM
First Name
Email
Phone:
Address:
Zipcode
Last Name
Date of Birth
Emergency Number
City
Gender
Male
Female
What's the name treatment or service?
Are you currently taking any medications or supplements? If so, please provide a list.
Have you had any recent surgical procedures or skin treatments? If yes, please specify.
Tick on the box if your answer is Yes.
Do you have any pre-existing medical conditions (e.g., heart disease, diabetes, autoimmune disorders) or chronic skin conditions (e.g., psoriasis, eczema)?
Have you ever had an adverse reaction to cosmetic treatments, including lasers or ultrasound treatments?
Have you experienced any skin infections, herpes outbreaks, or cold sores in the treatment area recently?
Have you had significant sun exposure or used tanning beds in the treatment area within the past two weeks?
Do you have a history of keloid or hypertrophic scarring?
Have you undergone any facial injectable treatments (e.g., dermal fillers, Botox) in the past six months?
Are you allergic to any medications, topical agents, or materials used in cosmetics or skincare products?
Do you have a history of allergic reactions to anesthetics or numbing creams?
Are you currently pregnant, planning to become pregnant, or breastfeeding?
Have you given birth or had a miscarriage within the last six months?
Do you have any upcoming events or commitments that might affect your ability to follow post-treatment care instructions?
What is your maritual status?
Married
Single
Divorced
Separated
Widowed
Do you have a clear understanding of the expected downtime and recovery period following the procedure?
No
Yes
Are you aware of the potential side effects and risks associated with treatments, as discussed in the consent form?
No
Yes
Do you understand that multiple sessions may be required for optimal results?
No
Yes
**Treatment Information:** I, the undersigned, consent to undergo Medical Aesthetic Treatments at Prime Health. **Description of Medical Aesthetic Treatments:** Medical Aesthetic Treatments are non-surgical cosmetic procedures designed to improve skin texture, reduce wrinkles, and address various skin concerns. These treatments involve the use of advanced medical devices to target and rejuvenate specific areas of the skin. It is important to note the following aspects: - **Skin Rejuvenation Procedures:** These procedures may include laser-based treatments and ultrasound energy treatments, which are intended to stimulate collagen production and skin renewal. - Potential side effects include redness, swelling, and discomfort at the treatment site, temporary changes in skin pigmentation, and in rare cases, scarring or infection. **Potential Side Effects:** I understand that Medical Aesthetic Treatments may have potential side effects, which include, but are not limited to: 1. Redness and swelling at the treatment site. 2. Mild discomfort or pain during and after the procedure. 3. Temporary changes in skin pigmentation. 4. Blistering or crusting of the skin. 5. Scarring (rare). 6. Infection (rare). 7. Changes in skin texture. 8. Prolonged redness or erythema. 9. Unsatisfactory results. I acknowledge that the severity and duration of these side effects may vary and that Prime Health will take necessary precautions to minimize risks. **Use of Images:** I hereby grant permission to Prime Health to use any photographs taken during my treatment for promotional purposes, including on websites, social media, brochures, and other marketing materials, without compensation. **Waiver of Liability:** I acknowledge that Prime Health has explained the nature of the treatments, their potential risks, and benefits. I understand that while all necessary precautions will be taken, no guarantees are made regarding the outcome. I agree not to hold Prime Health, its staff, or affiliates responsible for any dissatisfaction or complications arising from the treatment. I confirm that I have read and understood this consent form in its entirety, have had the opportunity to ask questions, and received satisfactory answers. By signing below, I voluntarily consent to undergo Medical Aesthetic Treatments at Prime Health.
Patient Policy
I agree to the terms & conditions
Your Signature
Clear
Submit
bottom of page