Med spa consent form template

I, Client name (the "Client"), consent to the treatment described below at Med spa name (the "Clinic"), to be performed by Provider name and credentials, under the supervision of the Clinic's medical director, Medical director. Date: Consent date.

1. The treatment

• Treatment: Treatment name
• Area or areas treated: Treatment areas
• Product or device: Product or device
• Sessions usually needed: Expected sessions
• Price: Treatment price Price basis

2. Health screening

The Client has completed the Clinic's medical history form and adds the following, writing "none" where nothing applies:

• Medicines and supplements, including blood thinners, aspirin, fish oil and isotretinoin in the last six months: Medicines and supplements
• Allergies, including to lidocaine or other numbing agents: Allergies
• History of cold sores, keloid scars, autoimmune disease or poor wound healing: Relevant history
• Earlier cosmetic treatments in this area, such as fillers, implants or threads, with dates: Earlier treatments
• Sun exposure or tanning in the last two weeks: Recent sun exposure
• I am pregnant, trying to become pregnant, or breastfeeding.

3. Results

The provider has explained what the treatment is meant to do. Results vary from person to person, often take more than one session, and most are temporary, so maintenance treatments may be needed. The Clinic cannot promise a particular result, and a result the Client doesn't like is not by itself grounds for a refund.

4. Risks

The Client understands that the treatment can cause side effects, including:

• Common and short-lived: redness, swelling, bruising, tenderness, itching or a headache.
• Less common: infection, an allergic reaction, uneven results, lumps, changes in skin color, blisters or burns from light and energy devices, and drooping of an eyelid or brow after a wrinkle-relaxing injection.
• Rare but serious: an injected filler can enter or press on a blood vessel and block blood flow, which can damage the skin and, in rare cases, cause vision loss or stroke.

The Client will call the Clinic right away at Clinic urgent phone for severe or worsening pain, skin that turns white, gray or dusky, blisters, fever, or any change in vision, and will call 911 for an emergency.

5. Alternatives

Other options, including different products, other treatments, skin care alone or no treatment, have been discussed. The Client chooses this treatment freely.

6. Before and after

The Client has received written preparation and aftercare instructions and will follow them. Not following them, for example by exercising, tanning or using active skin products too soon, can affect results and raise the risk of complications.

7. Photographs

The Clinic takes before and after photos for the Client's medical record. They are confidential. The Clinic may use them in its advertising, website or social media only if the Client ticks this box: I agree, and I understand I can withdraw this permission in writing for future use.

8. Payment

Payment is due at the time of treatment. Product that has been injected or applied can't be returned or refunded. Touch-up policy: Touch-up policy.

9. Consent

The Client has read this form, asked the questions they had, and had them answered. The Client may withdraw consent at any time before treatment begins. This consent covers the series of sessions described in section 1; a new treatment or product needs a new consent.

Client contact details

Date of birth: Date of birth Phone: Client phone Email: Client email

I have read and understood the risks in section 4, my health answers are complete and true, and I am at least 18 years old.