Skin Boosters – 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 receiving medical treatment or taking medications? *

Yes

No

If yes, please specify: *

Are you dealing with any of the following conditions :

Have you had recent cosmetic procedures (fillers, Botox, peels, laser)? *

Yes

No

If yes, please describe and provide dates: *

Treatment Goals and Preferences

Have you had injectable treatments or skin booster before? *

Yes

No

If yes , please let us know the date and type : *

Do you use any active skincare ingredients (acids, retinoids, vitamin C)? *

Yes

No

Do you wear SPF everyday? *

Yes

No

Procedure Information and Expectations

Skin boosters involve micro-injections of hyaluronic acid to hydrate and improve skin quality.

The procedure may involve mild discomfort. Topical anesthetic may be applied.

Multiple treatments may be necessary to achieve and maintain optimal results.

Common treatment areas: face, neck, décolleté, and hands.

Risks, Side Effects, and Acknowledgements

Please read and initial statements for the Skin Booster Treatment: *

I understand that skin booster treatments are minimally invasive and not permanent.

I acknowledge that mild swelling, redness, bruising, or tenderness may occur post-treatment.

I understand that rare risks include lumps, infection, allergic reactions, or asymmetry.

Skin Boosters – Comprehensive Consent and Concern Form

I agree to avoid alcohol, blood thinners, and intense physical activity for 24 hours post-treatment.

I confirm that I have disclosed all medical history and allergies accurately.

I consent to clinical photographs being taken for documentation purposes (not for public use without consent).

Client Declaration and Consent

Check the boxes for Skin Booster Treatment: *

I confirm that the information I have provided is accurate and complete.

I understand the procedure, benefits, risks, and aftercare related to skin booster treatment.

All of my questions have been answered to my satisfaction.

I voluntarily consent to undergo the skin booster treatment 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

Date: *

I agree to terms & conditions provided by the company.

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Skin Boosters – Comprehensive Consent and Concern Form

Treatment Goals and Preferences

Procedure Information and Expectations

Risks, Side Effects, and Acknowledgements

Client Declaration and Consent

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