General Medical Aesthetics Release Form / Hold Harmless

General Medical Aesthetics Release Form / Hold Harmless
I hereby consent to and authorize _________________________ to perform the following treatment:
_________________________________________________________________________________
Although it is impossible to list every potential risk and complication, I have been informed of possible
benefits, risks, and complications of this treatment. I also recognize there are no guaranteed results and
that independent results are dependent upon age, skin condition, and lifestyle and that there is the
possibility I may require further treatments of the treated areas to obtain the expected results at an
additional cost.
I have read and understand the post-treatment home care instructions. I understand how important it is to
follow all instructions given to me for post-treatment care. In the event that I may have additional
questions or concerns regarding my treatment or suggested home product/post-treatment care, I will
consult the practitioner immediately.
I have also, to the best of my knowledge, given an accurate account of my medical history, including all
known allergies, prescription drugs or products I am currently ingesting or using topically.
I have read and fully understand this agreement and all information detailed above. I understand the
treatment and accept the risks. All my questions have been answered to my satisfaction and I consent to
the terms of this agreement. I do not hold the technician (nor the establishment), whose signature
appears below, responsible for any of my conditions that were present, but not disclosed at the time of
this skin care procedure, which may be affected by the treatment performed today. I also release
__________________________________________of any liability that may arise from this procedure.
Client Name (Printed)
__________________________________________________________________
Client Name (Signature)
_________________________________________Date______________________
Health History Intake Form
Date: ______________
Name: ______________________________________________ Date of Birth: __________________________
Address: ________________________________ City: _______________________ State: _________________
Age: _______
Phone #: (______) ________________ Email: _____________________________________________________
Known allergies and reactions:

____________________________________________________________________________________
List current medications (topical & oral):

____________________________________________________________________________________
Please check any of the following that apply:

Cancer Eczema
Diabetes Immune Disorder
Hysterectomy Skin Disease/Disorder
AIDS/HIV Varicose
Psoriasis Veins/Phlebitis
Spinal Injury Pacemaker/Defibrillator
Keloid Scarring Thyroid Disorder
Menopause Blush/Redden Easily
High/ Low Blood Pressure Depression/Anxiety
Claustrophobia Bruise Easily
Hormone Imbalance Lupus
Hepatitis A/B/C Fibromyalgia
Rosacea Circulation Disorder
Cold Sores Metal Implants/ Pins
Blood Clot Disorder Heart Disease
Other: ____________________________________________________________________
1. Do you smoke? Y / N
2. Do you wear contacts? Y / N
3. Do you follow a restricted diet? Y / N

What is your daily consumption of Water? _____oz. Caffeine? ____oz. Alcohol? _____oz.
Are you currently under the care of a physician or dermatologist? Y/ N If so, explain.
_____________________________________________________________
Any surgeries within the last 6 months? Y / N If so, explain.
_____________________________________________________________
Any dermal injections/fillers with in the last 6 months? Y / N If so, explain.
_____________________________________________________________
Are you using any products that contain Retin –A, Renova, Adapalene Hydroxyl Acid, Differin,
Glycolic Acid, AHA/BHA, Salicylic Acid, Lactic Acid, Retinol/Vitamin A, Accutane or any other
prescription or over the counter skin product? Y N
Have you used any of these products in the past 3 months? Y N If so, explain.
_______________________________________________________________________
Have you ever had any allergic reaction to any skin products? Y N If so, explain:
________________________________________________________________________
Client Consent: I understand, have read and completed the questionnaire truthfully. I agree that this
constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand
that withholding information or providing misinformation may result in contraindications and/or
irritation to the skin from treatments received. I am aware that it is my responsibility to inform the
practitioner of my current medical or health conditions and to update this history. I understand that the
services offered are not a substitute for medical care and any information provided by the practitioner is
for educational purposes only and not diagnostically prescriptive in nature. I understand that the
information herein is to aid the practitioner in giving better service and is completely confidential. The
treatments I receive here are voluntary and I release _____________________________________
and______________________________ from any liability and assume full responsibility thereof.
Patient Signature ________________________________________________Date: ___________
Practitioner Signature ____________________________________________Date: ___________

Name: _____________________________ Date of Birth: _____________________________
Address: _____________________________ Phone: _________________________________
Email Address: _____________________________
Photographic Consent:
I consent to photographs being taken before, during and after each procedure. I agree to
these photos being stored electronically in my case file and will be used only with my written
consent for promotional purposes.
Patient Signature: ___________________________________Date: ___________________
Patch Test Waiver: (please initial where appropriate)

(A) I understand that a skin test can determine whether or not I will experience a reaction to
the products used within 48 hours prior to the treatment. However, I accept this will be
inconclusive as to whether I have an allergic reaction at any time in the future.
I therefore waive my option to an allergy test and wish to proceed with treatment. _______
(B) I have undergone or been offered an allergy test prior to my initial treatment. I therefore
release (practitioner name/company) ____________ from liability related to any
allergic reaction I may experience associated with either the application of the
pretreatment cream or any other products used before, during and after my procedure,
immediately or at a later date. ________
Patient Signature: ___________________________________ Date: ___________________
In case the case of an emergency , please contact:
Name: ____________________________ Number: ________________________
Relation: ___________________________

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General Medical Aesthetics Release Form / Hold Harmless

I hereby consent to and authorize _________________________ to perform the following treatment:

__________________________________________of any liability that may arise from this procedure.

Client Name (Printed)

Client Name (Signature)

Name: ______________________________________________ Date of Birth: __________________________

Address: ________________________________ City: _______________________ State: _________________

Phone #: (______) ________________ Email: _____________________________________________________

Known allergies and reactions:

List current medications (topical & oral):

Please check any of the following that apply:

2. Do you wear contacts? Y / N

3. Do you follow a restricted diet? Y / N

Any surgeries within the last 6 months? Y / N If so, explain.

Any dermal injections/fillers with in the last 6 months? Y / N If so, explain.

Patient Signature ________________________________________________Date: ___________

Practitioner Signature ____________________________________________Date: ___________

Address: _____________________________ Phone: _________________________________

Email Address: _____________________________

Patient Signature: ___________________________________Date: ___________________

Patch Test Waiver: (please initial where appropriate)

Patient Signature: ___________________________________ Date: ___________________

In case the case of an emergency , please contact:

Name: ____________________________ Number: ________________________

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