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.
Name: / technology or product brand:
Lot # / expiry: / parameters:
Treatment area — describe in detail:
Units / ml / passes: / cost:
Name: / technology or product brand:
Lot # / expiry: / parameters:
Treatment area — describe in detail:
Units / ml / passes: / cost:
Name: / technology or product brand:
Lot # / expiry: / parameters:
Treatment area — describe in detail:
Units / ml / passes: / cost:
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
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:
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:
Pre-Treatment Instructions
Avoid blood thinners, aspirin, NSAIDs, fish oil, and alcohol — duration and specifics:
Avoid sun exposure for (days):
Aftercare by treatment type — downtime expectations, ice, arnica, avoidance of heat, exercise, lying flat, sun protection:
Per-treatment cost (sum):
Package pricing — bundle details:
Payment methods accepted:
Cancellation policy details:
Month 3 appointment date:
Pregnancy / Breastfeeding Final Confirmation
Patient signature (printed name):
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Provider signature (printed name):
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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.