Healthcare Deep Pore Cleansing Consent Form

Healthcare Deep Pore Cleansing Consent Form

Patient Information

Date of Birth:    Gender: Female Male Non-binary/Other

Insurance Information (if applicable)

Medical / Skin History

Do you have a history of: Keloid scarring Cold sores / herpes simplex Severe cystic acne

Are you pregnant or breastfeeding? Yes No

Have you taken isotretinoin (Accutane) in the past 6 months? Yes No

Procedure Description & Consent

I, the patient named above, authorize the licensed clinician to perform a Deep Pore Cleansing procedure, which may include cleansing, steaming, manual and mechanical extractions, exfoliation, topical products, and finishing serums or masks. The procedure is elective and intended to improve skin clarity, extract comedones, and reduce surface oils.

I understand the clinician will use professional judgment to select products and techniques appropriate for my skin type. I have disclosed all relevant medical, allergy, and medication information and acknowledge that failure to disclose such information may increase the risk of adverse effects.

Risks, Potential Complications, and Expected Effects

I acknowledge that risks associated with this procedure include, but are not limited to: temporary redness, swelling, tenderness, bruising, petechiae, mild bleeding during extractions, irritation, dry or flaky skin, hyperpigmentation or hypopigmentation, infection, scarring, and allergic reaction to topical agents. Results cannot be guaranteed and multiple treatments may be required. If active infection or contraindications are present, treatment will be deferred.

Alternatives and Right to Decline

Alternatives to deep pore cleansing include at-home topical regimens, prescription medications, chemical peels, and deferring treatment. I understand I may withdraw consent at any time prior to the start of the procedure without penalty. If I withdraw during the procedure, I will notify the clinician immediately.

Post-Treatment Care

I agree to follow post-treatment instructions provided by the clinician, including sun protection, avoiding harsh topical agents, and refraining from picking or exfoliating treated areas until healed. Failure to follow aftercare may increase risk of complications.

Photography and Records

I authorize before and after photographs for clinical documentation and treatment planning. Photographs will be kept as part of my medical record. Photographs used for promotional or educational purposes require separate written authorization; I indicate consent for promotional use below.

I consent to clinical photographs for my medical record only.
I consent to use of de-identified photographs for educational or promotional purposes

HIPAA / Privacy & Authorization

I acknowledge receipt of the clinic’s privacy practices and understand how my health information will be used for treatment, payment, and healthcare operations. I authorize release of my treatment information to:

This authorization is valid until:

Acknowledgment and Consent

By signing below I certify that I have read and understand this Consent Form, that all of my questions have been answered to my satisfaction, and that no guarantees concerning the results of the procedure have been made. I voluntarily consent to the performance of the Deep Pore Cleansing procedure described above. I release the clinician and the clinic from liability for complications or untoward outcomes except in cases of willful misconduct or gross negligence.

I understand that if, during the procedure, an unforeseen condition requires a different or additional procedure, the clinician will stop and obtain my consent before proceeding unless immediate action is required for my safety.

I understand that payment for elective cosmetic services is my responsibility and that complications resulting from undisclosed medical information may not be covered by insurance.

Sign Now