Healthcare Threading Consent Form

HEALTHCARE THREADING CONSENT FORM

Patient Information

Insurance Information

Medical History

Have you had recent cosmetic procedures, injections, or laser treatments to the face within the past 6 weeks? Yes No

Procedure Details

Provider / Technician Name:

Procedure description: Threading is a mechanical method of hair removal using a cotton thread to remove hair from the follicle. The provider will remove unwanted hair from the indicated area(s) and may apply topical antiseptic or soothing product as needed.

Risks, Benefits, and Alternatives

I understand that the intended benefit of threading is temporary removal of unwanted hair with minimal downtime. Potential risks and complications include, but are not limited to: redness, irritation, swelling, folliculitis, ingrown hairs, bruising, transient or permanent pigment changes, scarring, allergic reaction to topical products, and risk of infection. Unusual reactions may occur despite adherence to standard care.

Alternatives to threading include tweezing, waxing, chemical depilatories, electrolysis, and laser hair removal. I have had the opportunity to ask questions about the procedure, risks, benefits, and alternatives and understand that no guarantees have been made concerning the results.

By initialing below, I acknowledge that the risks and alternatives were explained to me and I understand them: Initials:

Consent and Authorization

I hereby authorize the provider and staff to perform threading on the treatment area(s) indicated. I certify that I have provided a complete and accurate medical history and disclosed all medications, allergies, and prior procedures. I consent to the application of topical antiseptics, soothing agents, or other topical preparations as deemed necessary for safe treatment.

I understand that I may revoke this consent at any time prior to the procedure, but that revocation will not affect actions already taken in reliance on this consent. I agree to follow all aftercare instructions provided to reduce the risk of complications.

I authorize the provider to take clinical photographs for documentation and clinical care purposes only. Photographs used for training or promotional purposes require additional written authorization.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been offered access to the clinic’s privacy practices regarding the use and disclosure of my protected health information for treatment, payment, and healthcare operations. I consent to the use and disclosure of my health information as necessary to provide care, process claims, and coordinate treatment.

Authorization Duration

This consent remains in effect until the conclusion of the treatment and any immediate aftercare, unless otherwise revoked in writing. If a specific expiration is desired, enter expiration date:

Patient Statements and Certification

By signing below, I certify that I have read and fully understand the information contained in this form. I have had an opportunity to ask questions and all my questions have been answered to my satisfaction. I consent to proceed with threading treatment.

Sign Now