Healthcare Health SPA Form

HEALTH SPA CONSENT AND HEALTH QUESTIONNAIRE

Patient Information

Date of Birth:    Gender: Female Male Other Prefer not to say

Emergency Contact

Insurance Information (if applicable)

Treatment Requested

Select treatment(s):
Facial / Skin Treatment Chemical Peel Microdermabrasion
Laser / Light Therapy Injectables (Botox / Fillers) Waxing / Hair Removal
Body Treatment Other:

Medical History and Screening

Are you currently under the care of a physician for any medical condition? Yes No

Do you have any of the following? (check all that apply):
Heart disease Diabetes Epilepsy
Thyroid disorder Bleeding/clotting disorder Cancer
Autoimmune disease Hepatitis HIV
Rosacea Active cystic acne Keloid scarring

Are you pregnant or breastfeeding? Yes No

Use of specific medications/substances:
Have you taken isotretinoin (Accutane) in the past 6 months? Yes No
Do you use blood thinners (aspirin, warfarin, clopidogrel, etc.)? Yes No
Are you currently on steroids or immunosuppressive therapy? Yes No

Consent, Risks, and Acknowledgements

I, the undersigned, authorize the licensed practitioner or trained staff of this facility to perform the spa/aesthetic treatment(s) indicated above. I acknowledge that no guarantee or assurance has been made regarding the results that may be obtained.

I understand the nature of the proposed procedure(s), common risks, and potential complications, which may include but are not limited to infection, bruising, swelling, blistering, pigmentary changes, scarring, allergic reaction, prolonged redness or sensitivity, paradoxical hair growth (for hair removal), and need for additional treatments. I recognize that rare and unforeseen complications can occur.

I have disclosed all known medical conditions, medications, allergies, and prior procedures. I will notify staff of any changes in my health, medications, or pregnancy status prior to any treatment. I understand that failure to disclose such information may increase the risk of complications and may invalidate this consent.

I consent to photographs or digital images for the purpose of medical documentation and treatment comparison unless I indicate otherwise below: Yes No

I acknowledge that I have the right to ask questions and that these questions have been answered to my satisfaction. I understand that I may withdraw my consent at any time prior to the start of a treatment.

Financial and refund policies for spa treatments have been explained to me separately and I understand my payment obligations for services rendered.

Authorization and Release

By signing below I certify that the information I have provided is accurate and complete to the best of my knowledge. I authorize the performance of the requested treatment(s). I release this facility, its employees, and agents from liability for risks associated with the procedure that were disclosed and inherent to the treatment, except in cases of gross negligence or willful misconduct.

I authorize the use and disclosure of my protected health information, as necessary for treatment, payment, and healthcare operations. This authorization expires on the date specified below or upon revocation in writing. Authorization expiration date:

Acknowledgement of Receipt

I acknowledge that I have received, read, and understand the information provided above. I have had the opportunity to ask questions regarding my treatment plan and potential risks. I consent to proceed.

Date Reviewed:

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