Healthcare Facial Beauty Assessment

HEALTHCARE FACIAL BEAUTY ASSESSMENT

Patient Information

Date of Birth:    Gender: Female Male Other

Insurance Information (if applicable)

Medical History

Current medications (prescription, OTC, supplements):

Known allergies (medication, latex, topical products, food, other):

Prior facial surgeries, cosmetic procedures, or significant dermatologic treatments:

Chronic conditions (diabetes, hypertension, autoimmune, clotting disorders, etc.):

Please indicate if any of the following apply:

Taking blood thinners (aspirin, warfarin, clopidogrel, etc.) Isotretinoin within past 6 months Pregnant or breastfeeding Autoimmune or immunosuppressed Prior adverse reaction to injectable or topical cosmetic agents

Treatment Requested

Risks, Benefits, and Alternatives

I acknowledge that the proposed facial/cosmetic treatments carry risks including, but not limited to: bruising, swelling, erythema, infection, scarring, pigmentary changes, numbness, allergic reaction, asymmetry, unsatisfactory aesthetic result, and nerve injury. Some responses may be delayed or permanent. The likelihood and severity of risks varies by procedure and individual medical history.

Benefits commonly include improvement in texture, tone, and appearance in treated areas. Alternative options, including no treatment, medical therapy, or referral to a surgical specialist, have been discussed or are available upon request.

By checking the boxes below, I confirm understanding of these matters:

I understand the risks and potential complications described above.
I understand that results cannot be guaranteed and may require additional treatment.
Alternatives and post-procedure care have been discussed with provider.

Consent, Photography, and HIPAA Acknowledgement

I authorize the clinician and authorized staff to perform the dermatologic and cosmetic procedures agreed upon. I authorize application of topical agents and administration of injectables as indicated. I understand I may withdraw consent at any time prior to the procedure except where actions have already been reasonably taken in reliance on my consent.

I consent to clinical photography for the purpose of medical records and treatment planning. I understand photographs may be used anonymously for education or quality assurance unless I explicitly deny permission below.

Consent to treatment
Consent to photography for clinical record and treatment planning
Decline use of photographs for non-clinical (educational/marketing) purposes
I acknowledge receipt of the practice's privacy notice and understand how my protected health information may be used.

Patient Certification

I certify that the above information is accurate and complete to the best of my knowledge. I have disclosed all medical conditions, medications, and allergies relevant to facial cosmetic treatment. I understand that withholding information may increase the risk of complications. I have had the opportunity to ask questions and these have been answered to my satisfaction.

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