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:

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

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.

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