Treatment Plan & Informed Consent

This form documents the treatments planned for you, sets expectations, and records your informed consent. Please read every section carefully and ask questions before signing. Treatment will not proceed until this consent is complete.

Plan Header

Patient name:

Plan date:

Planning provider:

Treatment date:

Selected Treatments

Treatment 1

Name: / technology or product brand:

Lot # / expiry: / parameters:

Treatment area — describe in detail:

Units / ml / passes: / cost:

Treatment 2

Name: / technology or product brand:

Lot # / expiry: / parameters:

Treatment area — describe in detail:

Units / ml / passes: / cost:

Treatment 3

Name: / technology or product brand:

Lot # / expiry: / parameters:

Treatment area — describe in detail:

Units / ml / passes: / cost:

Expected Results

Realistic, treatment-specific outcomes the patient can expect:

Expected onset of visible result:

Expected duration of result:

Touch-up / re-treatment timing:

Realistic Expectations Statement

I understand outcomes vary individually based on anatomy, healing, and lifestyle

I understand my results may not match photos seen elsewhere or on social media

I understand multiple sessions may be required to reach my desired outcome

Risks & Side Effects

Universal risks include bruising, swelling, redness, asymmetry, pain, and infection. Treatment-specific risks include vascular occlusion for fillers, immune reaction or granuloma, paresthesia for toxin or nerve-adjacent injection, hyperpigmentation for laser, and scarring for invasive procedures. Please read carefully:

Acknowledge each major risk:

Bruising

Swelling

Asymmetry

Infection

Vascular complications

Scarring

Pigmentation change (hyper- or hypopigmentation)

Allergic reaction

Rare but Serious Risks

Rare but serious risks include anaphylaxis, vascular occlusion with potential vision loss for fillers, prolonged paresthesia, persistent granuloma, hospitalization for severe infection, and permanent skin damage. These events are uncommon but must be considered before proceeding:

I have read and understand the rare but serious risks listed above

Pre-Treatment Instructions

Avoid blood thinners, aspirin, NSAIDs, fish oil, and alcohol — duration and specifics:

Avoid sun exposure for (days):

Arrive with clean skin (no makeup, no SPF residue)

Eat a light meal before the appointment if prone to anxiety or fainting

Aftercare Instructions

Aftercare by treatment type — downtime expectations, ice, arnica, avoidance of heat, exercise, lying flat, sun protection:

I understand expected downtime

I will use ice / cool compress as instructed

I will avoid heat (sauna, hot yoga, hot showers) for the recommended period

I will avoid strenuous exercise and lying flat as advised

I will apply broad-spectrum SPF daily as advised

Pricing & Payment

Per-treatment cost (sum):

Package pricing — bundle details:

Deposit collected:

Balance due date:

Payment methods accepted:

Cancellation policy details:

I agree to the 48-hour cancellation policy

I understand a late cancellation forfeits the deposit

Follow-Up Schedule

Which follow-ups apply?

Week 1 follow-up

Week 2 follow-up

Week 4 follow-up

Month 3 follow-up

Week 1 appointment date:

Week 2 appointment date:

Week 4 appointment date:

Month 3 appointment date:

Photography Consent

I consent to pre-treatment photography

I consent to post-treatment photography

I consent to portfolio use with my face anonymized

Pregnancy / Breastfeeding Final Confirmation

I confirm I am not currently pregnant

I confirm I am not currently breastfeeding

I understand the risks if either of these change before treatment, and will inform the provider immediately

Signatures

Patient signature (printed name):

Provider signature (printed name):

Signing date:

Final Agreement

I have read this consent form, asked all the questions I have, and consent to the treatments listed

Thank you. A signed copy of this consent will be retained in your medical record. Treatment will proceed only after this form is fully signed.