Healthcare Threading Document

Healthcare Threading Document

Facility and Practitioner

Patient Information

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

Phone:    Email:

Relationship:    Phone:

Insurance Information (if applicable)

Medical History & Skin Assessment

Do you have bleeding disorders or take blood thinners? Yes No    Are you pregnant or breastfeeding? Yes No

Procedure Description

Procedure Date:    Area to be Treated:    Estimated Duration:

Description: Threading is a mechanical hair removal technique using a twisted thread to remove hair from the follicle. The practitioner will use sterile techniques and may apply topical cleansers or soothing agents as indicated.

Risks, Benefits, and Alternatives

Risks: I acknowledge the following potential risks which may include, but are not limited to: transient redness, swelling, bruising, pinpoint bleeding, folliculitis or infection, allergic reaction to topical products, post-inflammatory hyperpigmentation or hypopigmentation, scarring, and persistence or regrowth of hair. Rare complications include keloid formation and delayed healing.

Benefits: The intended benefit is removal and shaping of unwanted hair with minimal skin abrasion and immediate cosmetic improvement.

Alternatives: Alternatives include plucking/tweezing, waxing, depilatory creams, electrolysis, and laser hair removal. I have had the opportunity to discuss alternatives and ask questions.

Contraindications & Consent Details

I certify that I have informed the practitioner of all medical conditions, medications, allergies, and prior treatments. I understand that certain conditions may increase risk of complications and that the practitioner may refuse or postpone treatment if treatment is unsafe.

Use of Topical Agents: I consent to the use of topical cleansers, soothing agents, or topical anesthetic if recommended by the practitioner. Yes No

Aftercare & Post-Procedure Instructions

Aftercare includes gentle cleansing, avoidance of sun exposure and tanning, avoidance of harsh exfoliants for 48–72 hours, and application of recommended soothing agents. Contact the facility if signs of infection, worsening pain, or other concerning symptoms occur.

Privacy & Authorization

HIPAA Acknowledgment: I acknowledge that I have been provided with the facility's privacy practices regarding protected health information. I authorize the practitioner and staff to use and disclose my health information for treatment, billing, and healthcare operations as permitted by law.

Photography for Clinical Records: I consent to clinical photographs for documentation and treatment purposes. I understand that photographs used for education or marketing will not include identifying information without additional written consent. Consent Do not consent

Emergency Treatment Authorization: In the event of an emergency arising from the procedure, I authorize the practitioner and staff to obtain or provide emergency care as deemed necessary. Yes No

Authorization Expiration Date: This authorization and consent remain in effect until unless revoked in writing prior to that date.

Patient Certification

By signing below I certify that I have read and understand the foregoing information, that all my questions have been answered to my satisfaction, and that I freely consent to the described threading procedure and related care. I understand I may withdraw consent at any time prior to the procedure.

Printed Name:    Relationship to patient (if signing on behalf):

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