Dermalogica Facial – Comprehensive Consent and Concern Form

Client Information

Full Name *

Date of birth *

Gender *

Address

Street Address

City

Postal code

Phone Number *

Email Address *

Emergency Contact Name *

Emergency Contact Phone *

Medical History

Are you currently under medical supervision or taking medications? *

Yes

If yes, please provide details:

Are you currently experiencing or have you ever had any of the following conditions? (Please check all that apply): *

Are you currently experiencing or have you ever had any of the following conditions? (Please check all that apply):

Bleeding disorders or taking blood thinners

Respiratory conditions (e.g., asthma, chronic bronchitis)

Facial surgery or trauma in treatment area

Allergy to botulinum toxin or albumin

Pregnant or breastfeeding

None

Do you have a history of cold sores? *

Yes

Have you had previous Botox treatments? *

Yes

If yes, please specify date and treatment areas:

Treatment Goals and History

What are your primary concerns/goals for Botox?

What areas are you interested in treating? (e.g., forehead, crow’s feet, frown lines):

Have you had any recent cosmetic treatments (laser, filler, chemical peels)? *

Yes

If yes, please lest us know :

Procedure Information

Botox is a purified protein that temporarily relaxes muscles to reduce dynamic lines.

It is injected into specific facial muscles using a fine needle with minimal discomfort.

Effects typically begin within 3–7 days and last approximately 3–4 months.

Repeat treatments are required to maintain results.

Risks, Side Effects, and Acknowledgements

Please read and initial each statement regarding Botox : *

I understand that Botox is not permanent and results vary from person to person.

I understand that common side effects may include bruising, swelling, tenderness, or headache.

I understand that rare complications include eyelid drooping, asymmetry, infection, or allergic reaction.

I agree to avoid alcohol, aspirin, ibuprofen, and intense exercise for 24 hours post-treatment.

I understand that optimal results require follow-up and ongoing treatment.

I confirm that I have disclosed all medical history, medications, and allergies.

I consent to clinical photography for documentation (not for public use without consent).

Client Declaration and Consent

Check all boxes for Botox Treatment : *

I confirm the information provided is accurate and complete.

I have discussed the treatment plan, risks, benefits, and alternatives with my practitioner.

All my questions were answered to my satisfaction.

I voluntarily consent to receive Botox injections at Idens Laser Clinic.

By signing below, I confirm that I have read and understood the information provided and consent to proceed with the treatment.

Client Signature: *

Clear

Date: *

Practitioner Name (Print): *

Practitioner Signature: *

Clear

Deposit & Risk Acknowledgment Policy

Non-Refundable Deposit

I understand and agree that any deposit made for medical consultations, procedures, or treatments is non-refundable under all circumstances. This applies regardless of cancellation, rescheduling, or change of decision on my part.

Assumption of Risk

I acknowledge that all medical treatments, procedures, or interventions carry inherent risks. I have been informed of the potential benefits, risks, and alternatives related to my care, and I have had the opportunity to ask questions. I voluntarily assume full responsibility for any and all risks, outcomes, or complications that may arise from the medical care I receive. I release the provider and facility from liability for outcomes that are not guaranteed and may vary from patient to patient

Confirmation of Understanding

By signing below, I confirm that:

- I have read and fully understood this policy

- I understand the deposit is non-refundable.

- I accept and assume all risks related to my treatment.

- I sign this document voluntarily and without coercion.

Patient Name

Patient Signature:

Clear

Date: *

I agree to terms & conditions provided by the company.

Dermalogica Facial – Comprehensive Consent and Concern Form

Treatment Goals and History

Procedure Information

Risks, Side Effects, and Acknowledgements

Client Declaration and Consent

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