Dermal Fillers Consent Form | Bright Balance Wellness

Full Name:

Date of Birth:

Age:

Gender:

Female Male

Address:

Phone:

Email:

Emergency Contact Name:

Emergency Contact Phone:

Occupation

Referred By

MEDICAL HISTORY & CONTRANDICATIONS
Please check ALL that apply to you (past or present):

MEDICAL CONDITIONS

RECENT TREATMENTS (Within last 30 days)

LIFESTYLE FACTORS

Regular Sun Exposure / Tanning Bed Use Smoker / Tobacco User Alcohol Consumption (Frequent) High-Intensity Exercise Daily

SKIN ASSESSMENT & TREATMENT GOALS

Primary Skin Concerns (Select top 3):

Previous Microneedling Experience:

Do you understand the expected downtime and aftercare?

None 1–3 sessions 4+ sessions

List all current skincare products (Cleanser, Serum, Moisturizer, SPF, etc.):

I, ________________________, hereby acknowledge and agree to the following:

Procedure Understanding: I understand that microneedling is a cosmetic procedure that uses fine needles to create micro-injuries in the skin to stimulate collagen production. I have been informed of the steps involved, expected sensations, and post-treatment appearance.
Risks & Complications: I am aware that possible side effects include but are not limited to:
- Redness, swelling, bruising, itching, and peeling for several days.
- Temporary hyperpigmentation or hypopigmentation.
- Infection, scarring, or allergic reaction.
- Herpes simplex (cold sore) flare-up if prone.
- Lack of desired results.
Pre- & Post-Treatment Instructions: I agree to follow all instructions provided, including:
- Avoiding sun exposure, retinoids, acids, and certain supplements before treatment.
- Using recommended aftercare products and SPF 30+ daily.
- Not picking, scratching, or exfoliating treated skin.
Medical Disclosure: I affirm that all information provided is true and complete. I will inform my provider of any changes in my health or medications. I understand that withholding information may compromise my safety and treatment outcomes.
No Guarantees: I acknowledge that results vary and no specific outcome is guaranteed. Multiple sessions may be required.
Financial Policy:
- A non-refundable deposit is required to secure my appointment.
- Cancellation or reschedule requires 24 hours notice to avoid forfeiting deposit or being charged a fee.
- Late arrivals (15+ minutes) may be considered a no-show and charged accordingly.
Release of Liability: I voluntarily assume all risks associated with this procedure and release the provider, Birth Balance Wellness, and its staff from any liability arising from known or unknown complications, provided reasonable care has been given.
Photographic Consent: I consent to photographs being taken for medical records, progress tracking, and potentially for educational or marketing purposes (anonymous).