Thread Vein Treatment – 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

No

If yes, please provide details:

If yes, list allergens :

Treatment History and Skin Profile

Have you had thread vein treatment before (e.g., laser, IPL, sclerotherapy)? *

Yes

No

If yes, when and what was the outcome?

Have you had any cosmetic procedures in the area to be treated recently? *

Yes

No

Let us know :

Have you had any cosmetic procedures in the area to be treated previously ? *

Yes

No

Have you had history of post-inflammatory hyperpigmentation or scarring? *

Yes

No

Have you been exposed to the sun recently or used tanning products within the past 4 weeks? *

Yes

No

Do you currently use skincare products containing retinoids, acids, or bleaching agents? *

Yes

No

Areas of Concern and Goals

Which areas would you like to have treated for thread veins? (Please check all that apply) *

Face

Legs

Chest

Nose

Other option :

What do you hope to achieve with this treatment?

Do you currently have any open wounds, infections, or irritation in the treatment area? *

Yes

No

Are you currently using anticoagulants or medications affecting circulation? *

Yes

No

Have you been diagnosed with any vascular or circulatory conditions? *

Yes

No

Risks, Side Effects, and Acknowledgements

Please read and initial each statement regarding Thread Vein Treatment : *

I understand that thread vein treatments may use laser or IPL to target and collapse small blood vessels.

I acknowledge that multiple sessions may be required and individual results may vary.

I understand potential side effects include redness, bruising, swelling, pigmentation changes, or blistering.

I understand that rare risks include infection, scarring, or worsening of visible veins.

I agree to avoid sun exposure and follow pre- and post-treatment care guidelines provided by Idens Laser Clinic.

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

I understand that results are not guaranteed and may vary depending on individual skin and vascular characteristics.

I consent to the use of clinical photos for medical documentation purposes. These will not be shared without my permission.

Client Declaration and Consent

I confirm the above information is accurate and complete.

I understand the nature, purpose, and risks associated with thread vein treatment.

I have had the opportunity to ask questions and all were answered to my satisfaction.

I voluntarily consent to undergo thread vein 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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