Healthcare Threading Form

Healthcare Threading Form

Patient Information

Patient Name:    Date of Birth:

Phone:    Email:    Gender:

Relationship:    Phone:

Insurance Information (if applicable)

Policy / ID Number:    Group Number:

Medical History

Prior Surgeries / Procedures:

Chronic Conditions (e.g., diabetes, bleeding disorders):

Are you currently pregnant or trying to become pregnant? Yes     Do you have a history of keloids or poor wound healing? Yes

Procedure Description and Consent

Procedure to be performed: Eyebrow and facial hair removal by manual/threading technique. The practitioner will use cotton or thread to remove hair from the follicle. This is a superficial cosmetic procedure and is not a surgical intervention.

I acknowledge that the practitioner has explained the nature and purpose of threading, expected benefits, and potential alternatives. I understand that results may vary and multiple treatments may be required for desired effect.

Risks, Complications and Aftercare

I understand the commonly associated risks include, but are not limited to: temporary redness, swelling, minor bleeding, folliculitis (inflammation of hair follicles), skin irritation, infection, bruising, and in rare cases scarring or changes in pigmentation. Immediate hypersensitivity to topical products may occur.

Aftercare instructions have been provided and include keeping the treated area clean, avoiding harsh exfoliation and sun exposure for 48 hours, and using recommended topical agents if advised. I understand that failure to follow aftercare may increase the risk of complications.

Acknowledgement, Authorization and Release

By signing below I certify that I have read and fully understand this form, that all information provided is accurate to the best of my knowledge, and that I have had the opportunity to ask questions. I authorize the practitioner to perform threading as described and to provide or arrange such emergency care as may be deemed necessary in the event of an adverse reaction.

I release and hold harmless the practitioner, the facility, and their agents from liability arising from complications or adverse outcomes, except for gross negligence or willful misconduct. I understand that no guarantee has been made regarding the results.

I understand I may withdraw my consent at any time prior to or during the procedure. Withdrawal of consent does not release me from responsibility for charges for services already rendered.

Privacy and Release of Records (HIPAA Acknowledgment)

I acknowledge receipt of the facility's privacy practices and understand my rights regarding protected health information. I authorize disclosure of relevant medical information to emergency personnel, my insurer if applicable, and other providers as necessary for continuity of care and billing related to this procedure.

I consent to the use of photographs of the treatment area for clinical documentation, quality assurance, and internal record-keeping provided that such images will not be released publicly without my separate written consent.

HIPAA Acknowledgment: I acknowledge and consent to the terms above.

Patient Certification

I certify that I have disclosed all relevant medical information, that I understand the risks and benefits of threading, and that I consent to the procedure. I confirm that I am not under the influence of alcohol or drugs that would impair my ability to consent.

Are you signing as the patient or legal guardian? Patient    Legal guardian / authorized representative

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