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.
MEDICAL CONSENT FORM
First Name
Email
Phone:
Address:
Zipcode
Last Name
Date of Birth
Emergency Number
Emergency Name
City
Gender
Male
Female
Do you have insurance?
Yes
No
Insurance Company Name
What is your maritual status?
Married
Single
Divorced
Separated
Widowed
Insurance Number
Insurance Image
Upload supported file (Max 15MB)
ID Number
ID Image
Upload supported file (Max 15MB)
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?
I agree to receive text messages and emails regarding treatment information.
I accept terms & conditions
Your Signature
Clear
Submit
bottom of page