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
24-Hour Cancellation Policy:

We require a minimum of 24 hours' notice for any appointment cancellations or rescheduling. Failure to provide at least 24 hours' notice, or missing your scheduled appointment, will result in the forfeiture and deduction of that session from your pre-paid package.

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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