BEAUTYMD WOMEN'S SPA & WELLNESS CENTER

PATIENT CONSENT FORM

for beauty services & treatments

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Reffered by:

Emergency contact name:

Emergency contact phone number:

Emergency Contact Relationship:

MEDICAL BACKGROUND

PLEASE LIST ANY SKIN OR HEALTH CONDITIONS YOU ARE EXPERIENCING

HAVE YOU EVER OR ARE YOU TAKING:

RETIN A

ACCUTANE

None of the above

IF YES, PLEASE SPECIFY WHEN WAS THE LAST TIME THIS PRODUCT USED:

ARE YOU CURRENTLY TAKING ANY ORAL OR TOPICAL ANTIBITOICS:

Oral

Topical

None of the above

IF YES, WHAT IS THE NAME OF THE ANTIBIOTIC

HOW OFTEN DO YOU EXERCISE ?

ARE YOU CURRENTLY PREGNANT, TRYING TO CONCEIVE OR BREASTFEEDING?

YES

NO

DO YOU SMOKE?

YES

NO

HOW MUCH UV EXPOSURE DO YOU GET (SUN, TANNING BEDS, COMMUTING IN CAR)?

PLEASE LIST ALL ALLERGIES , SUPPLEMENTS, MEDICATIONS OR RECENT SURGERIES:

Please check all that apply: Do you have any of the following? Any active infections such as:

If yes, please, specify area:

Please check all that apply: Do you have any of the following? If yes specify:

diabetes

bleeding disorders

None of the above

Other

Are you taking blood thinners? If yes please specify why, if no, just write NO

CLIENT INFORMED CONSENT TO TREATMENT:

I.

consent and authorize Beauty Med Inc. to perform any facial procedures, body treatment, laser hair removal and other related skin care services.

SERVICES:

Please check next to the following statements below to acknowledge consent.

I have voluntarily elected to undergo this treatment/ procedure after its nature and purpose has been explained to me, along with the risks involved. Although it is impossible to list every potential risk and complication, I have been informed of the possible benefits, risks and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition and lifestyle. I have read and understand the post-treatment home care instructions. I have also best to my knowledge, given an accurate account of my medical history.

I have read and fully understand this agreement and all information detailed above. I do not hold the esthetician responsible nor Beauty Med Inc for any of my conditions that were present but not disclosed at the time of the procedure, which may be affected by the treatment performed today.

Signature

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Treatment of a Minor

Signature of parent or guardian:

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