Dermasence Client Intake Form

Dermasence Client Intake & Service Agreement

WHEREAS, Dermasence (the Provider) is engaged in the provision of professional dermatological and aesthetic skin care services; and

WHEREAS, the Client seeks evaluation, treatment, and related services from Provider, and agrees to provide accurate medical history and to follow pre- and post-treatment instructions; and

WHEREAS, the parties wish to document the Client intake information and memorialize the terms governing performance of the services, payment, confidentiality and other material terms.

Client Information

Date of Birth:

Medical History & Current Medications

Do you have any allergies to medications, topical products or foods? None Known (specify below)

Are you pregnant or nursing? Yes No

Have you taken oral isotretinoin (Accutane) in the past 12 months? Yes No

Skin Assessment & Treatment History

Primary skin concern(s):

Prior cosmetic procedures within last 6 months (fill all that apply): Botox/Dysport Dermal Fillers Laser/IPL Chemical Peel None

Scope of Work

Describe the proposed treatment plan, procedures to be performed, and anticipated number of sessions. This description constitutes the Scope of Work for which the Client gives consent.

Payment Terms

Treatment Fee (total):

Balance due schedule:

Late fee for overdue balances:

Accepted payment methods: Card Cash Check

Term and Termination

Term Commencement Date:

Anticipated Termination/Completion Date:

Either party may terminate this agreement for material breach or by providing written notice: Notice period (days):

Upon termination, Client remains responsible for all fees for services performed and for non-refundable deposits specified above. Provider may retain records and photographs necessary for treatment continuity and legal compliance.

Confidentiality

All personal health information disclosed in this form and in the course of treatment will be treated as confidential in accordance with applicable privacy laws. Provider may disclose health information when required by law or where necessary to provide medical care (e.g., referral to another clinician).

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the state of without regard to its conflict of law principles.

Entire Agreement

This document, together with any attached or referenced consent forms and patient records, constitutes the entire agreement between Client and Provider regarding the subject matter hereof. Any amendment must be in writing and signed by both parties.

Client Acknowledgments and Consents

I certify that the information I have provided is complete and accurate to the best of my knowledge. I consent to the treatments described in the Scope of Work, and I acknowledge that Provider has explained potential risks, benefits and alternatives.

Photography and Use of Images: I consent to clinical photography for treatment documentation and internal use. I do not consent to photography.

Cancellation and No-Show Policy: I understand that missed appointments or cancellations without required notice may result in forfeiture of deposit or assessment of a cancellation fee.

All medical information provided is truthful and complete.

I understand the risks and potential complications associated with the procedures.

I agree to follow pre- and post-care instructions provided by Provider.

Additional Notes

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