Anti-Wrinkle Consultation and Consent Form

1. Client Demographic Information *

First Name *

Last Name *

Address Line 1 *

Address Line 2

Email *

Phone Number *

Select Gender (Optional)

Birthday

Referred By

Medical History & Skin Analysis

2. Are you currently under the care of a doctor or dermatologist?

YesNo

3. If "Yes" please specify4. Do you have any of the following conditions? Please answer truthfully, this ensures your treatment is safe and effective5. If "Yes" to any of these including current medication" or "Other Medical Condition", please specify6. Areas of concern (tick all that apply):7. If "Other" please specify8. When is the appointment scheduled? *

Cosmetic Treatment History

9. Please tick all that apply:

Anti-wrinkle injections in the pastDermal fillers in the pastSkin boosters/mesotherapy in the pastLaser or light-based treatment in the past 6 weeksChemical peels or microneedling in the past 6 weeksFacial surgery or dental treatment in the past 6 weeksNone of the above

10. If yes, please specify area and date

Contraindication Check

Anti-wrinkle injections cannot be performed if any absolute contraindications apply, and may require postponement or additional precautions if relative contraindications are present. It is essential to answer all questions honestly to ensure safe and appropriate treatment.

11. Please tick any that apply:

Pregnancy or breastfeedingKnown allergy to botulinum toxin or formulation ingredientsActive infection at the intended injection siteNeuromuscular disease affecting muscle functionNone of the above

12. Please tick any that apply:

Recent aesthetic treatment in the same areaHistory of severe bruising or bleeding disorderUse of anticoagulants or blood-thinning medicationActive autoimmune flare-upUncontrolled medical conditionNone of the above

13. Are you currently on any of the following?

Retinol / Vitamin AAHA/BHA exfoliantsPrescription acne treatment (for example isotretinoin)Anti-inflammatory or steroid medicationBlood-thinning medication or supplementsOther active products/medicationsNone of the above

Client's Consent (Mandatory)

Photographs are taken before and after treatment for medical documentation and client records.

14. Client Consent (Mandatory) Please confirm each statement: *

I confirm that I have read, understood, and agree to follow the pre- and post-treatment information guide provided with this consultation and consent form.I confirm that the information I have provided is accurate, and I have disclosed all relevant medical history and allergies.I understand the general risks associated with aesthetic treatments, including bruising, swelling, asymmetry, infection, or temporary discomfort.I understand that results vary between individuals and that I may require further treatment for optimal or maintained results.I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction.I understand that all aesthetic treatments provide temporary results and will naturally wear off over time.I consent to photographs being taken for my medical record, with optional separate consent for marketing below.I consent to the processing of my personal data in accordance with the clinic's privacy policy and understand I can withdraw consent at any time.

15. Photo & Marketing Consent. *

I consent to my photos being used anonymously for training or educational purposes.I consent to my photos being used on social media/marketing.I do not consent to any use of my photos beyond my medical record.I consent to receive emails with offers and updates.

16. Please sign and date to confirm that you have read, understood, and agree to the statements above. *

I agree to use electronic records and signatures.16. Customer's Signature

Draw signature

Customer SignatureTimestamp captured on sign

Signature Date17. Client's Name *I agree to use electronic records and signatures.18. Employee's Signature

Draw signature

Employee SignatureTimestamp captured on sign

Employee Signature Date19. Employee's Name

Note: Customers will not see the employee signature field when filling form online.

Practitioner Notes (For Internal Use Only)

20. For "Other", please specify area:Assessment:Batch Number & Expiry Date:Treatment Given / Units Used:Post-Treatment Comments:

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Anti-Wrinkle Consultation & Consent Form

Anti-Wrinkle Consultation & Consent Form