BEAUTY MD PATIENT CONSENT FORM

for beauty services & treatments

Women’s Wellness & Fitness center 8015 188 Street Hollis NY 11423

First name*

Last name*

Email*

Phone*

Birthday*

Month

Day

Year

Country/Region*

Address*

City*

Zip / Postal code*

Reffered by:

Emergency contact name:*

Emergency contact phone number:*

Emergency Contact Relationship:*

MEDICAL BACKGROUND

PLEASE LIST ANY SKIN OR HEALTH CONDITIONS YOU ARE EXPERIENCING *

HAVE YOU EVER OR ARE YOU TAKING: *

RETIN A

ACCUTANE

None of the above

IF YES, PLEASE SPECIFY WHEN WAS THE LAST TIME THIS PRODUCT USED:

ARE YOU CURRENTLY TAKING ANY ORAL OR TOPICAL ANTIBITOICS: *

Oral

Topical

None of the above

IF YES, WHAT IS THE NAME OF THE ANTIBIOTIC

HOW OFTEN DO YOU EXERCISE ?*

ARE YOU CURRENTLY PREGNANT, TRYING TO CONCEIVE OR BREASTFEEDING?*

YES

DO YOU SMOKE? *

YES

HOW MUCH UV EXPOSURE DO YOU GET (SUN, TANNING BEDS, COMMUTING IN CAR)?*

PLEASE LIST ALL ALLERGIES , SUPPLEMENTS, MEDICATIONS OR RECENT SURGERIES: *

Please check all that apply: Do you have any of the following? Any active infections such as:*

psoriasis

eczema

dermatitis

vitiligo

None of the above

Other

If yes, please, specify area:

Please check all that apply: Do you have any of the following? If yes specify: *

Keloid scarring

polycystic ovary syndrome (PCos)

thyroid disorder

autoimmune disease

None of the above

Other

Please check all that apply: Do you have any of the following? If yes specify: *

diabetes

bleeding disorders

None of the above

Other

Are you taking blood thinners? If yes please specify why, if no, just write NO*

CLIENT INFORMED CONSENT TO TREATMENT:

I.*

consent and authorize Beauty Med Inc. to perform any facial procedures, body treatment, laser hair removal and other related skin care services.

SERVICES:*

Please check next to the following statements below to acknowledge consent. *

I have not used a scrub, Retin-A or glycolic peel in the last 72 hours.

I understand that with any treatment certain risks are involved and that any complications or side effects from known or unknown causes could occur. I freely assume these risks.

I am not epileptic and do not have heart or circulation problems.

I agree to adhere to all safety precautions and home skin care programs, as recommended by my Beauty Med Inc Esthetician or Nurse Practitioner

I am over 18 years old in age or I have parent consent co-signed below.

I will call to inform Beauty Med Inc. of any complications or concerns as soon as they occur

Possible side effects to facial treatments are: Mild redness, even bruising in some instances, dry skin and flaking.

I have been off Accutane for at least 12 months

I am aware that I am financially responsible for this treatment and full payment is expected immediately after my procedure

The nature and purpose of the treatment have been explained to me, and any questions I may have regarding this procedure have been explained to my satisfaction.

I have voluntarily elected to undergo this treatment/ procedure after its nature and purpose has been explained to me, along with the risks involved. Although it is impossible to list every potential risk and complication, I have been informed of the possible benefits, risks and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition and lifestyle. I have read and understand the post-treatment home care instructions. I have also best to my knowledge, given an accurate account of my medical history.

I have read and fully understand this agreement and all information detailed above. I do not hold the esthetician responsible nor Beauty Med Inc for any of my conditions that were present but not disclosed at the time of the procedure, which may be affected by the treatment performed today.

Signature*

Date picker*

Treatment of a Minor

Signature of parent or guardian:

Date picker

BEAUTY MD PATIENT CONSENT FORM

for CO₂ Fractional Laser Treatment

BEAUTY MD

Women’s Wellness & Fitness center

8015 188 Street

Hollis NY 11423

First name*

Last name*

Birthday

Month

Day

Year

Phone*

Email*

Address*

1. Purpose of CO₂ Fractional Laser Treatment

CO₂ fractional laser treatment is a skin resurfacing procedure that uses laser energy to target fine lines, wrinkles, scars, pigmentation, and overall skin texture. The laser creates microscopic injuries to stimulate collagen production, leading to skin rejuvenation and tightening.

2. Procedure

• A topical anesthetic will be applied to the treatment area to minimize discomfort.

• The laser will be used to create controlled micro-injuries in the skin.

• Patients may experience a warming sensation during the procedure.

• Post-treatment redness, swelling, and peeling are expected as part of the healing process.

3. Risks and Potential Complications

I acknowledge that CO₂ fractional laser treatment involves risks, including but not limited to:

• Redness, swelling, and discomfort lasting several days to weeks

• Skin peeling, scabbing, or temporary hyperpigmentation

• Hypopigmentation (lightening of the skin)

• Infection, if post-care instructions are not followed

• Scarring or prolonged healing in rare cases

• Reactivation of cold sores (herpes simplex virus) in prone individuals

I understand that while every effort will be made to achieve the best results, outcomes cannot be guaranteed and multiple sessions may be required.

4. Contraindications & Medical History

I understand that CO₂ fractional laser treatment may not be suitable if I have:

• Active skin infections, including cold sores or acne breakouts

• A history of keloid scarring or poor wound healing

• Recent use of Accutane (within the last 6–12 months)

• Uncontrolled diabetes or other medical conditions that impair healing

• Pregnancy or breastfeeding

• Recent excessive sun exposure or tanning

I certify that I have provided my full medical history and disclosed all medications, allergies, and health conditions to the provider.

5. Pre-Treatment & Post-Treatment Care

I agree to follow all pre- and post-treatment care instructions provided by my provider, including:

• Avoiding sun exposure and using SPF 30+ sunscreen daily

• Refraining from picking or peeling skin during healing

• Using prescribed or recommended skincare to aid recovery

• Avoiding harsh treatments (chemical peels, retinoids, exfoliation) for the recommended period

I understand that failure to follow these instructions may increase my risk of complications.

6. No Guarantees & Multiple Sessions

I acknowledge that results vary based on individual skin type and condition. Multiple treatments may be required to achieve the desired outcome, and no specific result is guaranteed.

7. Payment Responsibility

I understand that CO₂ fractional laser treatment is an elective cosmetic procedure not covered by insurance. I agree to be financially responsible for all costs associated with my treatment, and I understand that no refunds will be issued once the procedure has begun.

8. HIPAA Compliance & Privacy

I acknowledge that my personal health information will be kept confidential and protected under the Health Insurance Portability and Accountability Act (HIPAA). My information will only be shared with healthcare professionals involved in my care or as required by law.

9. Release of Liability & Hold Harmless Agreement

I voluntarily consent to CO₂ fractional laser treatment and release BEAUTY MD and its staff from any liability related to potential side effects or complications, except in cases of gross negligence.

10. Voluntary Consent

I have read and fully understand this consent form. I have had the opportunity to ask questions and have received satisfactory answers. I voluntarily consent to CO₂ fractional laser treatment and acknowledge that I can withdraw my consent at any time before the procedure.

MEDICAL BACKGROUND

PLEASE LIST ANY SKIN OR HEALTH CONDITIONS YOU ARE EXPERIENCING *

HAVE YOU EVER OR ARE YOU TAKING: *

RETIN A

ACCUTANE

NONE OF THE ABOVE

IF YES, PLEASE SPECIFY WHEN WAS THE LAST TIME THIS PRODUCT USED:

ARE YOU CURRENTLY TAKING ANY ORAL OR TOPICAL ANTIBITOICS: *

ORAL

TOPICAL

NONE OF THE ABOVE

IF YES, WHAT IS THE NAME OF THE ANTIBIOTIC

HOW OFTEN DO YOU EXERCISE ?*

ARE YOU CURRENTLY PREGNANT, TRYING TO CONCEIVE OR BREASTFEEDING?*

YES

DO YOU SMOKE?*

YES

HOW MUCH UV EXPOSURE DO YOU GET (SUN, TANNING BEDS, COMMUTING IN CAR)?*

PLEASE LIST ALL ALLERGIES , SUPPLEMENTS, MEDICATIONS OR RECENT SURGERIES: *

Please check all that apply: Do you have any of the following? Any active infections such as:*

PSORIASIS

ECZEMA

DERMATITIS

VITILIGO

NONE OF THE ABOVE

Other

If yes, please, specify area:

Please check all that apply: Do you have any of the following? If yes specify:*

Keloid scarring

Polycystic ovary syndrome (PCos)

Thyroid disorder

Autoimmune disease

None of the above

Other

Please check all that apply: Do you have any of the following? If yes specify*

Diabetes

Bleeding disorder

None of the above

Other

Are you taking blood thinners? If yes please specify why, if no, just write NO*

Patient Signature Date:*

Month

Day

Year

Patient Signature*

Provider Date

Month

Day

Year

Provider Signature