Healthcare Patient Skinboosters Consent Form

Healthcare Patient Skinboosters Consent Form

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History

Please indicate if any apply:

Bleeding disorder or taking anticoagulant medication    Autoimmune or immunodeficiency disorder    Pregnant or planning pregnancy    Breastfeeding

Isotretinoin (Accutane) within past 6 months    Systemic steroid or immunosuppressive therapy    Recent facial procedure / filler within past 2 weeks

Procedure Description

I consent to treatment with skinboosters (intradermal injectable hyaluronic acid or other mesotherapy formulations) administered by a licensed clinician. Target area(s): . Number of planned sessions: .

The anticipated benefits include improved skin hydration, texture, and appearance. Results vary by individual. Multiple sessions may be required to achieve and maintain results.

Risks and Potential Complications

I acknowledge that the following risks, while uncommon, can occur as a result of skinbooster injections. I understand and accept these potential complications:

Bruising and prolonged swelling    Infection at injection site    Allergic or hypersensitivity reaction

Persistent lumps or nodules    Asymmetry or irregular contours    Scarring or delayed healing

Vascular occlusion with rare tissue loss    Temporary or permanent pigmentation changes    Pain or discomfort at the injection site

Alternatives and Expectations

The available alternatives include no treatment, topical therapies, laser/non-invasive procedures, or other injectable modalities. I understand that results are not guaranteed and that additional treatments may be necessary.

I have had the opportunity to ask questions about the procedure, risks, benefits, expected recovery, and alternatives, and my questions have been answered to my satisfaction.

Pre- and Post-Procedure Instructions

I agree to follow pre-procedure instructions including avoidance of blood-thinning medications and supplements as advised. I will notify the clinician if I develop an active infection, cold sore, or skin irritation in the treatment area prior to my scheduled treatment.

HIPAA / Privacy & Photography Consent

I acknowledge receipt of the clinic's privacy practices. I authorize the release of relevant medical information to my insurer for purposes of claims related to this procedure when required.

I consent to clinical photography for medical records, treatment planning, and internal quality assurance.    I consent to use of de-identified images for educational or marketing purposes (optional)

Patient Certification and Consent

By signing below I certify that the information I have provided is true and complete to the best of my knowledge. I understand the nature of the proposed skinboosters treatment, the expected benefits, known risks, and possible complications listed above. I consent to the performance of the procedure and any necessary aftercare by the licensed clinician and staff.

I understand that in the event of an adverse reaction or medical emergency I will be provided appropriate medical care and that the clinic may seek emergency treatment as needed. I accept financial responsibility for services rendered that are not covered by insurance.

Sign Now