Healthcare Beauty Spa Intake Form

Healthcare Beauty Spa Intake Form

Patient Information

Full Legal Name:

Date of Birth:     Gender:

Insurance Information (if applicable)

Insurance Provider:

Medical History & Contraindications

Current medications (prescription, topical, supplements):

Known allergies (medications, latex, adhesives, topical agents):

Please check any conditions that apply:

Diabetes    Heart disease    Hypertension

Autoimmune disorder    Bleeding disorder or on blood thinners    History of keloid scarring

Rosacea    Psoriasis    Eczema

Taken isotretinoin (Accutane) within past 12 months    Pacemaker/Implanted device

Recent sunburn or active tan    Waxing, bleaching, or hair removal in treatment area within 2 weeks

Consent for Treatment

Description of proposed treatment(s):

Risks and benefits: I understand that cosmetic and skin treatments may involve risks including, but not limited to, redness, irritation, swelling, blistering, infection, scarring, hypo- or hyperpigmentation, bruising, allergic reaction to topical agents, and unsatisfactory cosmetic outcome. While most reactions are temporary, some may be permanent. There are no guarantees as to the result of treatment. I understand that additional treatments may be required to achieve the desired result.

My right to refuse or withdraw: I understand that I may refuse or withdraw consent for treatment at any time prior to the procedure. If I withdraw consent during a procedure, additional risks may occur and I accept responsibility for any resulting complications.

By checking the box below I consent to receive the described treatments and acknowledge that my practitioner has explained the intended benefits, common adverse effects, and reasonable alternatives.

I hereby consent to the treatment(s) described above.

Privacy, Photography & Authorization

HIPAA and personal health information: I acknowledge that I have received or been offered the practice's privacy notice concerning the use and disclosure of my personal health information. I authorize release of necessary medical information to my insurance carrier for purposes of claims and payment where applicable.

I acknowledge receipt of the spa's privacy practices and authorize use of my health information as described above.

Photography release: I consent to the taking of clinical or cosmetic photography for the purpose of documentation and treatment assessment. I understand that photographs will be used for medical records and may be used for educational or promotional purposes only if additional written consent is provided.

I consent to before-and-after photography for my treatment record.

Financial Responsibility & Cancellation

Financial responsibility: I understand that payment is due at the time of service. I am responsible for any charges not covered by my insurance, including co-payments, deductibles, and fees for non-covered services. I authorize the spa to charge my card on file for outstanding balances if I fail to remit payment.

Cancellation and no-show policy: I understand that failure to provide timely notice of cancellation may result in a cancellation fee. Repeated missed appointments may require prepayment for future services.

Acknowledgment

By signing below I certify that the above information is true and complete to the best of my knowledge. I have read and understand the consent statements and agree to the terms herein. I will notify the practitioner of any changes to my medical history prior to subsequent treatments.

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