Patient Information
Treatment(s) to be Performed Today
General Health Declaration
Please confirm you do NOT have any of the following (or have disclosed to your practitioner):
Pregnancy or breastfeeding
Active skin conditions or infections in treatment areas
Blood clotting disorders or anticoagulant medications
History of keloid or abnormal scarring
Allergies to any products or medications
Recent aesthetic treatments (within 2 weeks)
Any other conditions that may affect treatment safety
General Risks
I understand that aesthetic treatments carry general risks including but not limited to:
Pain, discomfort, bruising, swelling, and redness
Infection (rare with proper aftercare)
Unsatisfactory results or asymmetry
Temporary or permanent changes in skin sensation
Need for additional treatments or corrections
Patient Acknowledgements
By signing below, I confirm that:
I have had a consultation and understand the treatment(s) being performed
I have had the opportunity to ask questions and they have been answered
I have disclosed all relevant medical history, allergies, and medications
I understand the general and specific risks explained to me
I have received and understood aftercare instructions
I understand results are not guaranteed and may vary
I consent to photographs for my medical records
I will contact the clinic immediately if I experience any complications
I am over 18 years of age
I consent to the treatment(s) listed above being performed by the named practitioner
Data Protection Notice (GDPR): Your personal and medical information will be stored securely in accordance with UK GDPR and the Data Protection Act 2018. Your data will only be used for the purposes of your treatment and care. You have the right to access, rectify, or request deletion of your data.
I have read and understood this consent form and agree to proceed with the treatment(s) listed above.
Practitioner Name (Print)